Recipient

Sunrise Care Home

First report 26 Oct 2015•Latest report 26 Oct 2015

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: 0%
Concerns addressed: 0
Stated actions: 0

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.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Sunrise Care Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

26 Oct2015
Birmingham and Solihull
Concerns raised10
1. Failure to complete documentation contemporaneously
2. Lack of staff awareness of the Falls Prevention Policy
3. Failure to escalate falls to appropriate senior staff
1. Failure of senior staff to correctly review falls incident forms
2. Inaccurate completion of 15 minute observation forms
3. Policy of treating a resident’s first fall as isolated without further action
4. Failure to complete the falls tracker
5. Failure to complete the falls monthly log daily
6. Policy of delaying escalation to the falls team until three falls
7. Failure to correctly record falls
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Allan Richard Beasley · 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

Allan Richard Beasley, who had vascular dementia, was admitted to a care home after he could no longer manage at home and experienced multiple falls. Following a further fall, he was diagnosed with cervical spine fractures, developed a chest infection, deteriorated and died. Concerns included inadequate falls-risk assessment, failures to record and escalate falls, inaccurate observation records, and incomplete monitoring and review.

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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete documentation contemporaneously
Wider context from the report
“(4) Documentation is not completed contemporaneously but at the end of the shift. ”
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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff awareness of the Falls Prevention Policy
Wider context from the report
“(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff. ”
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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate falls to appropriate senior staff
Wider context from the report
“(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff. ”
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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of senior staff to correctly review falls incident forms
Wider context from the report
“(8) The falls incident forms were not correctly reviewed by senior staff. ”
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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate completion of 15 minute observation forms
Wider context from the report
“(3) 15 minute observation forms were found to be inaccurate as staff in the office were completing the form when not seeing the patient. In addition the observation forms were felt to be inaccurate as a member of staff signed for observations when it was found they were undertaking another task. ”
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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Policy of treating a resident’s first fall as isolated without further action
Wider context from the report
“(5) The home has a policy that the first fall of a resident is treated as an isolated incident and no further action is taken. ”
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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete the falls tracker
Wider context from the report
“(7) The falls tracker was not completed for Mr Beasley. ”
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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete the falls monthly log daily
Wider context from the report
“(2) The falls monthly log was not completed on a daily basis as it should have been. The log was not completed for June as staff were too busy. This resulted in trends being missed and staff being unaware of the frequency of Mr Beasley’s falls. ”
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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Policy of delaying escalation to the falls team until three falls
Wider context from the report
“(6) The home has a policy that they only escalate to the falls team if a resident has had 3 falls. ”
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 Sunrise Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to correctly record falls
Wider context from the report
“(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff. ”
Open source report

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 raised10

Failure to complete documentation contemporaneously

Lack of staff awareness of the Falls Prevention Policy

Failure to escalate falls to appropriate senior staff

Failure of senior staff to correctly review falls incident forms

Inaccurate completion of 15 minute observation forms

Policy of treating a resident’s first fall as isolated without further action

Failure to complete the falls tracker

Failure to complete the falls monthly log daily

Policy of delaying escalation to the falls team until three falls

Failure to correctly record falls