69 How has this enquiry been undertaken? What are the findings of the enquiry? If any gaps or omissions in care/practice were identified, please give details. As the residential home is a secure environment, Mr O should not have been able to exit the building. It has been identified that Mr O observed that pressing the fire alarm buttons releases the doors, although when this incident happened, a check on the fire alarm button of the side door did not open the door. Mr O appears to have excited the building either through the front or side door. The last documented observation was 45 minutes before the Police found Mr O. Mr O should have been on 15-minute checks and therefore this was not carried out as stated in the Care Plan which staff have failed to do. The Manager is taking action with the staff involved. It has to be acknowledged that this situation could have been more serious, and harm could have been caused. The home has acted in addressing the fire alarm situation and is having certain release buttons relocated to above the door so that Mr O is less likely to use this again. Home is also reviewing whether Mr O needs 1-1 support. The home has made the Supervisory body aware that Mr O needs to be assessed under the DoLS framework and has been waiting for assessment prior to this incident. What action will be taken as a result of this enquiry to include formal/informal action taken with the organisation and or adult(s)? Please include any learning and recommendations. The home to look at ways where Mr O can be more occupied with activities as he likes to be kept busy, this will then prevent further incidents happening. It is also hoped that Mr O will continue to settle within the home and that visits by his wife will become less stressful for him when she is leaving the building. Organisation - the home has taken on board that they need to evidence all information and that if a resident is on 15 minutes checks that these are carried out and all documented. Are there any continuing risk factors for the adult at risk/ others If so what actions will be taken to minimise these risks? Although the Fire door release buttons are being relocated, there is the potential for Mr O to observe where they are and try again. If Mr O exits the building again the potential is that serious harm could be caused particularly with the home being located on quite a busy road. Have the contents of this report been discussed with the adult at risk or their representative Yes X Discussion with Home Manager and statements from Staff who were responsible for Mr O at the time of the incident, confirm that he was last observed in the building 45 minutes previously. There was no fire alarm set off which would have released the doors for Mr O to get out, therefore staff were not aware he had exited the building. It has since been established that one of the side door’s alarms was faulty and Mr O is likely to have followed a relative out of this door or even the main entrance door.
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