The Limes

Private and voluntary organisations · Residential care home

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First report 16 Apr 2024•Latest report 16 Apr 2024

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Norfolk

    AI-generated summary

    Edith Jane ALDEN · 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

    Edith Jane Alden, a resident assessed at very high risk of falls, left a communal area unnoticed and unsupervised on 13 September 2021, fell in the garden and suffered severe head injuries. She died on 25 September 2021. Concerns included unclear and inconsistent care plans and risk assessments, insufficient supervision and staffing, and the use of unlocked communal-area access for residents at very high risk of falls.

    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 The Limes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide carer supervision for very high-risk residents in communal areas

    Wider context from the report

    “3. Residents deemed at very high risk of falls were, and still are, allowed in communal areas with no carer present. ”
    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 The Limes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to prevent falls through timely intervention when very high-risk residents mobilise

    Wider context from the report

    “6. Residents deemed as at very high risk of falls were, and still are, in their bedrooms with a call bell and no other means to alert staff if they get out of bed and mobilise, this includes leaving their room and entering corridor areas. I am concerned this will lead to carers responding to a fallen resident, rather than preventing the fall. ”
    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 The Limes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the inspection report to accurately reflect evidence about staffing and supervision

    Wider context from the report

    “5. The Inspection Report dated 6 October 2022, carried out following Mrs Alden’s death, found “There were enough staff on duty to meet people’s needs and people told us they never had to wait long for assistance. The registered manager had reviewed how staff were working and deployed staff in a way that meant that the right staff were in the right places when needed. This meant people in communal areas were never left alone ...” This sentence is not supported by the evidence heard at inquest. ”
    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 The Limes; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of consistent and clear fall-risk mitigation requirements in care plans and risk assessments

    Wider context from the report

    “1. Care Plans and Risk Assessments were not consistent and clear as to what steps were required to mitigate the risks of Mrs Alden falling. ”
    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 The Limes; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of an effective means to alert staff when very high-risk residents mobilise from bedrooms

    Wider context from the report

    “6. Residents deemed as at very high risk of falls were, and still are, in their bedrooms with a call bell and no other means to alert staff if they get out of bed and mobilise, this includes leaving their room and entering corridor areas. I am concerned this will lead to carers responding to a fallen resident, rather than preventing the fall. ”
    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 The Limes; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing capacity for the number of residents

    Wider context from the report

    “4. Staffing levels may be insufficient for the number of residents. Evidence was heard that “staff can’t be everywhere at once”. ”
    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 The Limes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of staff to understand required fall-risk mitigation measures

    Wider context from the report

    “2. Staff were unclear in evidence as to what was required in respect of Mrs Alden to mitigate the risks of her falling. ”
    Open source report
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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