PFD report

Marion Glover · Prevention of Future Deaths report

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Issued 12 Oct 2020•Manchester South

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised2

  1. Failure to restrict resident departures or observe foyer areas
    Part of recurring concern: Failure to reliably supervise and monitor residents in care accommodation
  2. Unsuitable accommodation for residents suffering cognitive illnesses and confusion
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

    Implement enhanced pre-admission risk assessments covering cognitive illness and confusion for prospective Melbourne Court tenants.

    Stated by Y1 Capital LtdStated completedThe respondent said that this action was complete when they made their response on 14 January 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 restrict resident departures or observe foyer areas

Wider context from the report

“On exploration of this issue, it became apparent that in the absence of any restriction on residents leaving the building or observation of the foyer area there is a serious risk that such residents suffering cognitive illnesses/confusion can unknowingly leave the building. In the circumstances Melbourne Court does not appear to be suitable accommodation for residents who are suffering cognitive illnesses and confusion. ”

Is this part of a recurring concern?

Yes — Failure to reliably supervise and monitor residents in care accommodation.

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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

Unsuitable accommodation for residents suffering cognitive illnesses and confusion

Wider context from the report

“On exploration of this issue, it became apparent that in the absence of any restriction on residents leaving the building or observation of the foyer area there is a serious risk that such residents suffering cognitive illnesses/confusion can unknowingly leave the building. In the circumstances Melbourne Court does not appear to be suitable accommodation for residents who are suffering cognitive illnesses and confusion. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Implement enhanced pre-admission risk assessments covering cognitive illness and confusion for prospective Melbourne Court tenants.

Verbatim wording from the response

“• Continued development of shared processes in ensuring that all risks are fully assessed pre-admission to Melbourne Court to include cognitive illnesses and confusion.”

Source location

2021-0004-Response-from-Able-Care-and-Support-Services-Ltd
Page 1 · response
Published 14 January 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.4

  1. 1

    Introduce EMAR software to maintain real-time medication records and reduce medication errors.

    Stated by Y1 Capital LtdStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  2. 2

    Conduct annual, or earlier needs-led, reviews of care plans and associated risk assessments, recording actions and updating plans for staff.

    Stated by Y1 Capital LtdStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  3. 3

    Implement On-Care digital care-management and alert-escalation processes to record care, concerns, responses and risk-mitigation measures.

    Stated by Y1 Capital LtdStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  4. 4

    Introduce a falls-management reporting form recording falls and follow-up actions to reduce or mitigate further falls.

    Stated by Y1 Capital LtdStated completedThe respondent said that this action was complete when they made their response on 14 January 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

Introduce EMAR software to maintain real-time medication records and reduce medication errors.

Verbatim wording from the response

“• EMAR (Electronic Medication Administration Record) software has been introduced allowing care staff to update MAR sheets automatically and enabling the care office to have an accurate view of resident's medications in real time thus reducing medication errors.”

Source location

2021-0004-Response-from-Able-Care-and-Support-Services-Ltd
Page 2 · response
Published 14 January 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

Conduct annual, or earlier needs-led, reviews of care plans and associated risk assessments, recording actions and updating plans for staff.

Verbatim wording from the response

“• Scheduled annual reviews, or sooner should changes in the resident's needs be identified, of residents care and support plans with associated risk assessments to mitigate and further reduce risks to include those linked with cognitive illnesses, confusion and falls. Resulting actions required post review are recorded on Care Planner software and if identified, allied health professionals are contacted for advice and direction. Care and support plans are updated and shared with relevant care staff.”

Source location

2021-0004-Response-from-Able-Care-and-Support-Services-Ltd
Page 2 · response
Published 14 January 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

Implement On-Care digital care-management and alert-escalation processes to record care, concerns, responses and risk-mitigation measures.

Verbatim wording from the response

“• On-Care digital care management software enabling care staff to record care delivery and all interaction with residents. The system enables care staff to raise an alert with the office if they should have any concerns or issues associated with a resident they care for. The office ensures that all alerts are promptly dealt with, linked information recorded on On-Care on how the raised alert has been actioned, measures put in place, and progress in resolving issues raised.”

Source location

2021-0004-Response-from-Able-Care-and-Support-Services-Ltd
Page 2 · response
Published 14 January 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

Introduce a falls-management reporting form recording falls and follow-up actions to reduce or mitigate further falls.

Verbatim wording from the response

“• Introduction of Falls Managing report form. The form is to report all falls, whether witnessed or not, with follow up actions we have made in reducing/mitigating any further falls to the individual or other residents.”

Source location

2021-0004-Response-from-Able-Care-and-Support-Services-Ltd
Page 2 · response
Published 14 January 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