PFD report

Amy Chiverall · Prevention of Future Deaths report

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Issued 14 Apr 2021•Manchester North

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
7

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to provide accessible call alarms for residents at moderate or high risk of falls
    Part of recurring concern: Inadequate control of falls risks
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Direct staff to attach call bells to people rather than walls, including enabling at-risk independent people to wear them.

    Stated by RochCare (UK) LtdStated completedThe respondent said that this action was complete when they made their response on 27 May 2021.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide accessible call alarms for residents at moderate or high risk of falls

Wider context from the report

“The Court heard the home do not use pendant call alarms. This was described as a business decision. The Home has 18 residents of mixed falls risk but less than half would be of a moderate or high risk of falls. The Court was concerned that for those residents a fixed call bell may not be of assistance, as in this case, as it would be out of reach when required. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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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

Direct staff to attach call bells to people rather than walls, including enabling at-risk independent people to wear them.

Verbatim wording from the response

“• The info points all people to have the call bell attached to the person, not to the wall. For those people who do independently and have capacity, but are at risk of falls, they can wear the call bell to summon help when required.”

Source location

2021-0178-Response-from-Rochcare-Redacted
Page 1 · response
Published 27 May 2021

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Order a chair alarm that sounds when someone stands up.

    Stated by RochCare (UK) LtdStated completedThe respondent said that this action was complete when they made their response on 27 May 2021.
  2. 2

    Change the process for ensuring staff know and understand policies.

    Stated by RochCare (UK) LtdStated completedThe respondent said that this action was complete when they made their response on 27 May 2021.
  3. 3

    Provide staff with record-keeping training.

    Stated by RochCare (UK) LtdStated completedThe respondent said that this action was complete when they made their response on 27 May 2021.
  4. 4

    Establish a falls-prevention information folder containing assessments, equipment, care needs, checks, policies and post-falls tools.

    Stated by RochCare (UK) LtdStated completedThe respondent said that this action was complete when they made their response on 27 May 2021.
  5. 5

    Put staff management arrangements into place.

    Stated by RochCare (UK) LtdStated completedThe respondent said that this action was complete when they made their response on 27 May 2021.
  6. 6

    Provide risk training covering incidents and follow-up arrangements.

    Stated by RochCare (UK) LtdStated completedThe respondent said that this action was complete when they made their response on 27 May 2021.

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

Order a chair alarm that sounds when someone stands up.

Verbatim wording from the response

“• Chair alarm call has been ordered, this is similar to a bell alarm that sounds when someone stands up.”

Source location

2021-0178-Response-from-Rochcare-Redacted
Page 1 · response
Published 27 May 2021

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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

Change the process for ensuring staff know and understand policies.

Verbatim wording from the response

“• The process of ensuring staff know and understand policies has changed.”

Source location

2021-0178-Response-from-Rochcare-Redacted
Page 1 · response
Published 27 May 2021

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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

Provide staff with record-keeping training.

Verbatim wording from the response

“• Staff record keeping. They have since had record keeping training.”

Source location

2021-0178-Response-from-Rochcare-Redacted
Page 1 · response
Published 27 May 2021

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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

Establish a falls-prevention information folder containing assessments, equipment, care needs, checks, policies and post-falls tools.

Verbatim wording from the response

“• The current required information has been picked up and full information is at the forefront of the day. This includes a folder titled falls prevention project. It has relevant assessments, all equipment, care needs and checks (conversion) along with falls policy, post-falls tool.”

Source location

2021-0178-Response-from-Rochcare-Redacted
Page 1 · response
Published 27 May 2021

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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

Put staff management arrangements into place.

Verbatim wording from the response

“• The management of staff have been ordered and put into place.”

Source location

2021-0178-Response-from-Rochcare-Redacted
Page 1 · response
Published 27 May 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

Provide risk training covering incidents and follow-up arrangements.

Verbatim wording from the response

“• Risk training including incidents that have occurred, and what is being followed up.”

Source location

2021-0178-Response-from-Rochcare-Redacted
Page 1 · response
Published 27 May 2021

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

Data last updated 7 September 2026