Recipient

St Johns Nursing Home Limited

First report 1 Oct 2021•Latest report 1 Oct 2021

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 8

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

8stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from St Johns Nursing Home Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

1 Oct2021
South London
Concerns raised3
1. Failure to routinely check window restrictors during regulatory inspections
2. Unavailability of weekend reception monitoring to prevent residents following visitors through the exit door
3. Failure to prevent unaccompanied exit by residents without capacity or ability to assess risk
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Advertise for a weekend receptionist to monitor the door at weekends.
  Stated planned
2. Action
  Position a staff member by the side gate during fire drills and disable the gate's exit code.
  Stated completed
3. Action
  Station the administrator in reception during normal working hours to monitor the entrance and secure door closure.
  Stated completed
1. Action
  Restrict visitor access codes and require staff accompaniment for entry and exit.
  Stated completed
2. Action
  Advise staff about unauthorised exits and require secure door closure and vigilance around reception.
  Stated completed
AI-generated summary

Stephen Martin Verrall · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Stephen Martin Verrall fell from the window of his first-floor room at St John’s Nursing Home and died from his injuries two days later. Concerns included an inadequate window restrictor, lack of a window-maintenance risk assessment, unrestricted windows remaining years later, and risks of residents leaving the home unaccompanied.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Johns Nursing Home Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to routinely check window restrictors during regulatory inspections
Wider context from the report
“(1) Care Quality Commission – I was informed that CQC did not routinely check window restrictors on inspections. I was told that it was the responsibility of providers to comply with regulatory requirements in this regard. Whilst that is uncontroversial, the death in this case, and the fact that there remained unrestricted windows in August 2021 nearly four years after this death, demonstrated that checks by the regulator are required. Responsive checks after incidents are not sufficient to prevent deaths. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Johns Nursing Home Limited; that does not assign responsibility.
PFD Monitor interpretation
Unavailability of weekend reception monitoring to prevent residents following visitors through the exit door
Wider context from the report
“(2) St John’s Nursing Home – I heard that Stephen had managed to leave the home unaccompanied on several occasions. The opportunity to do so for those without capacity and without the ability to assess risk poses a risk to their lives. I was told that the reception is not manned on the weekends and there is a risk that residents may follow visitors through the door when they leave. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to St Johns Nursing Home Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to prevent unaccompanied exit by residents without capacity or ability to assess risk
Wider context from the report
“(2) St John’s Nursing Home – I heard that Stephen had managed to leave the home unaccompanied on several occasions. The opportunity to do so for those without capacity and without the ability to assess risk poses a risk to their lives. I was told that the reception is not manned on the weekends and there is a risk that residents may follow visitors through the door when they leave. ”
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Advertise for a weekend receptionist to monitor the door at weekends.

Verbatim wording from the response
“iv. We are advertising for a weekend receptionist to ensure going forwards the door is monitored at weekends. In the interim, all staff are ensuring the door is closed securely behind them;”

Source location
2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
Page 1 · response
Published 14 October 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Position a staff member by the side gate during fire drills and disable the gate's exit code.

Verbatim wording from the response
“v. We ensure that when there is a fire drill a member of staff stands by the side gate. This gate is key coded for exit, which is disabled during fire drills. The member of staff ensures residents do not leave the premises;”

Source location
2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
Page 1 · response
Published 14 October 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Station the administrator in reception during normal working hours to monitor the entrance and secure door closure.

Verbatim wording from the response
“iii. During normal working hours, the administrator is situated in the reception area and ensures staff securely closes the door behind them;”

Source location
2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
Page 1 · response
Published 14 October 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Restrict visitor access codes and require staff accompaniment for entry and exit.

Verbatim wording from the response
“i. Visitors are not given the key code, which is changed regularly, for entry or exit so are accompanied by a member of staff;”

Source location
2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
Page 1 · response
Published 14 October 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Advise staff about unauthorised exits and require secure door closure and vigilance around reception.

Verbatim wording from the response
“ii. All staff have been advised of the potential problem of residents leaving through the front door. When letting visitors in and out of the building staff ensure the door is securely closed behind them and they have been advised to be alert around the reception area during the course of their working day/night;”

Source location
2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
Page 1 · response
Published 14 October 2021
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Failure to routinely check window restrictors during regulatory inspections

Unavailability of weekend reception monitoring to prevent residents following visitors through the exit door

Failure to prevent unaccompanied exit by residents without capacity or ability to assess risk

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.5

Actions described in response 5