Albert Rowlands

“1. Despite the care home having identified the risks associated with Mr [name redacted] wandering unsupervised and falling, the control measures put in place (including Zimmer frame use and the bedside pressure mat), these did not eliminate the risk. Mr [name redacted] (on the occasion of this accident and at other times) was plainly able to get out of bed without his alarm sounding, and to move around without always using his Zimmer frame. I believe that care home should consider whether more can be done to ensure”

“The indication that care staff felt pressured should be reflected upon, in the context of whether they are able to devote as much time to vulnerable residents as might be required. By inference, the errors made in respect of the mis-locating of the pressure mat and the incorrect position of the bed are likely to have occurred because the carer involved was rushing. The care home should consider whether its staffing levels are appropriate, both in this context and in terms of how quickly a member”

“Given that he was found in a pool of urine, it is reasonable to infer that Mr [name redacted]' reason for getting out of bed was to use the toilet. The journey to the nearest toilet required him to walk through two heavy doors and along a corridor. This must have presented a risk to somebody with his background. Consideration should be given to whether residents generally are optimally located within the care home, having regard to their respective needs and risk profiles.”