Sylvia Prichard

“Mrs [name redacted] mobility care plan contained out of date and conflicting information”

“The Coroner is concerned that other residents' care plans may contain out of date and conflicting information”

“Mrs [name redacted] did not have a falls minimisation plan in place and the Manager of the care home was not aware that Avery Healthcare had a falls minimisation plan document which needed to be completed for residents at risk of falls”

“Audits show that, despite efforts to improve call bell response times, a significant number of call bells are still not responded to within two to five minutes”

“Since Mrs [name redacted] death Moorlands Lodge Care Home has introduced watches which can be worn on the wrist and used to attract immediate attention in the event of a fall or other medical emergency”

“The Coroner is concerned that Avery Healthcare's oversight and auditing measures failed to identify that the call bell response time policy was not being implemented at Moorlands Lodge Care Home for many months and further failed to identify that falls minimisation plans were not being completed for residents”