Recipient

The Limes

First report 16 Apr 2024•Latest report 16 Apr 2024

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care 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 The Limes linked to the concerns in each report. Select any concern, action or position to view the source wording.

16 Apr2024
Norfolk
Concerns raised7
1. Failure to provide carer supervision for very high-risk residents in communal areas
2. Failure to prevent falls through timely intervention when very high-risk residents mobilise
3. Failure of the inspection report to accurately reflect evidence about staffing and supervision
1. Lack of consistent and clear fall-risk mitigation requirements in care plans and risk assessments
2. Lack of an effective means to alert staff when very high-risk residents mobilise from bedrooms
3. Insufficient staffing capacity for the number of residents
4. Failure of staff to understand required fall-risk mitigation measures
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

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

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 raised7

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

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

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

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

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

Insufficient staffing capacity for the number of residents

Failure of staff to understand required fall-risk mitigation measures