Janet Smith

PINE VIEW CARE HOMES LTD 
Silver Birches 

Pine view 

418 – 420 Hinckley Road 

85 Lutterworth Road 

Leicester 
LE3 0WA 
OP, DE(4) 

Aylestone, Leicester 
LE2 8PJ 

OP, DE 

Professor C E Mason 
HM Senior Coroner for Leicester City and 
South Leicestershire 
HM Coroner’s Office 
The Town Hall 
Town Hall Square 
Leicester 
LE1 9BG 

19 July 2023 

Dear Sir, 

Regulation 28: Report to Prevent Future Deaths following the Inquest touching upon the death of Mrs Janet 
Smith 

Thank you for providing me with your Regulation 28: Report to Prevent Future Deaths report (Regulation 28 Report), 
dated 26 April 2023, following the conclusion of the Inquest touching upon the death of Mrs Janet Smith on 24 April 
2023 and for allowing me the opportunity to respond to the concerns which you have highlighted in your Regulation 
28 Report. 

Firstly, on behalf of Pine View Care Homes Ltd and the staff at the Silver Birches Care Home, I would like to pass on 
our condolences to the family of Mrs Smith for their loss. 

I am also grateful for the additional time that you have afforded me to respond to your Regulation 28 Report. I, along 
with the staffing team, have carefully considered your Regulation 28 Report in order to make and implement changes 
at the Silver Birches Care Home following the concerns that you have raised. 

Concerns 

Unfortunately,  the  risk  of  elderly  residents  falling  in  our  care  home,  and  in  care  homes  throughout  the  UK,  is  an 
inherent danger and can be an unpredictable and unforeseeable event. 

Although we have taken steps and have made improvements to our service, this risk cannot be eradicated completely. 
However, we hope that the changes and improvements that we have made will to try to mitigate this risk in the future 
and allay the concerns raised in your Regulation 28 Report. 

 
 
 
 
 
 PINE VIEW CARE HOMES LTD 
Silver Birches 

Pine view 

418 – 420 Hinckley Road 

85 Lutterworth Road 

Leicester 
LE3 0WA 
OP, DE(4) 

Aylestone, Leicester 
LE2 8PJ 

OP, DE 

At box 5 of the Regulation 28 report, I note that the two concerns you have identified are as follows: 

Concern 1 

At  the  time  of  Mrs.  Smith's  fall,  there  were  17  residents  and  2  carers.  One  carer  was  attending  a  resident 
upstairs and the other carer was outside the care home accompanying another resident who wished to have a 
cigarette. This meant that no carer was in the lounge area monitoring the residents. Accordingly, when Mrs. 
Smith left the lounge area she was not monitored as required. If she had been monitored, it is understood that 
she would have been offered assistance and, on a balance of probabilities, the fall that led to her death would 
not have occurred. 

It  was  understood  that  at  the  care  home  there  were,  and  still  is,  a  number  of  residents  with  challenging 
behaviour and care needs, and that for some activities of daily living 2 carers may be required. With only 2 
carers  on  a  shift,  it  is  foreseeable  that  residents  can  and  will  be  left  unattended.  It  is  also  foreseeable  that 
competing needs of the residents will mean that residents will be left unmonitored, and an unsafe environment 
created as occurred with Mrs. Smith. 

Concern 2 

Accordingly, there remains a concern that the provider has not done everything possible to mitigate the risk of actual or 
potential harm including death. 

I set out our response to the above concerns and the actions that we have taken below. 

Concern 1 

We have reviewed our policies and procedures and, for the benefit of the Coroner, we attach the following updated 
polices and a staffing hours analysis: 

1)  Staffing Hours Analysis  - this is reviewed monthly by management 
2)  Policy for Slips, Trips and Falls – this is reviewed yearly 
3)  Observations Policy – this is reviewed yearly 
4)  General Risks Assessments – continuously reviewed to assess risks 

Staffing Hours Analysis 

Each  of  our  residents  require  different  levels  of  support  and  care.  Accordingly,  their  dependency  levels  (i.e.  the 
amount of time staff should spend with each client) can differ at different times. We continuously review and monitor 
our residents’ support and care needs and these needs are then graded using our dependency level formula to establish 
the number of hours staff are required to spend with each resident. 

In summary, and as outlined in the attached  Staffing Hours Analysis, if a resident is graded “Self-Caring” or “Low 
Dependency” (i.e. they can walk without  assistance),  staff are required  to spend at least  1 – 2 hours a day with the 
resident. These residents have a good degree of independence, and their independence is respected. 

If a resident is graded “Medium Dependency” (i.e. needs to use a walking aid or be assisted, may use a wheelchair), 
staff are required to spend at least 3 hours per day with the resident. 

 
 
 
 
 PINE VIEW CARE HOMES LTD 
Silver Birches 

Pine view 

418 – 420 Hinckley Road 

85 Lutterworth Road 

Leicester 
LE3 0WA 
OP, DE(4) 

Aylestone, Leicester 
LE2 8PJ 

OP, DE 

If  a  resident  is  “High  Dependency”  (i.e.  walks  with  assistance  or  is  bedfast  /  chairfast”),  then  staff  are  required  to 
spend at least 4 hours a day with them. 

The  grading  system  allows  us  to  determine  staffing  levels  and  how  much  time  should  be  allocated  to  each  resident 
throughout  the  day  to  ensure  that  their  care  /  needs  are  adequately  and  appropriately  met  and  to  avoid  /  mitigate 
against the risk of residents falling or coming to mischief. 

We  now  employ  a  third  member  of  staff  during  the  day  from  9a.m.  to  7.00p.m.  Sometimes  2  staff  members  are 
required to assist residents located in different areas of the care home and to bring residents to different parts of the 
home  for  various  reasons.  A  third  member  of  staff  remains  in  the  lounge  area  at  all  times  to  monitor  and  assist 
residents. Therefore, a member of staff will be present in the lounge room to care for and monitor residents and ensure 
that residents are not left unattended. This will hopefully assist in trying to mitigate the risk of residents falling in the 
future as someone will always be present to monitor, assist and tend to residents at all times. 

Once we have calculated the care hours required, we then add a surplus hour cover and this covers us for emergencies, 
falls, stimulating residents, activities. By way of example, in the staffing analysis document attached, we need 38 but 
provide 57 hours - well above those that are stated in the methodology. 

General Risk Assessments 

Our  General  Risk  Assessments  Policy  (attached)  has  been  designed  for  staff  and  management  to  assess  risks, 
including the risks to residents when using the stairs and lift and slips, trips and falls, and how the risks identified are 
controlled and minimised. 

Our staff have familiarised themselves with our General Risk Assessment Policy and they are aware of their roles and 
duties to help minimise risks to patients. 

Observations Policy 

At  times,  a  resident’s  mood  and  behaviour  pattern  fluctuates  and  they  may  be  required  to  be  observed  at  increased 
levels to ensure their own safety, the safety of other residents and the safety of staff. Staff and management conduct a 
risk assessment for residents which is then regularly reviewed by management and staff to ensure the appropriate level 
of observation is in place for the resident’s needs at any particular time. 

Our Observation Policy (attached) sets out the different levels of observation which are required, which includes: 

1)  General Observation: All residents are observed at 2-hour intervals to monitor their wellbeing. 

2)  Enhanced  Observation:  This  is  for  residents  who  pose  a  potential  but  not  immediate  risk  to  themselves  and  other 

residents / staff. Residents are observed at hourly levels (as a minimum and shorter intervals if required). 

3)  Observations  by  Distance:  This  applies  to  residents  who  become  aggressive  and  agitated  whereby  staff  observe  the 

resident at a distance. 

4)  Observations of Residents who are in bed / sleeping: Staff are required to observe and monitor residents throughout the 
night  and  in  line  with  their  care  plans.  We  use  assistive  technology,  including  sensor  matts,  to  alert  staff  if  a  resident 
wakes up during the night and gets out of their bed. When a resident steps on the sensor matt, it alerts staff that a resident 
is up and out of their bed. Staff will then attend the resident immediately. 

 
 
 
 
 PINE VIEW CARE HOMES LTD 
Silver Birches 

Pine view 

418 – 420 Hinckley Road 

85 Lutterworth Road 

Leicester 
LE3 0WA 
OP, DE(4) 

Aylestone, Leicester 
LE2 8PJ 

OP, DE 

We have also installed sensor matts in in bedrooms, for those residents deemed at high risk of falls, with their consent 
or  through  a  DOLS  application  allowing  the  care  home  to  deprive  residents  due  to  having  no  capacity,  and  CCTV 
cameras throughout the home to enable management to monitor and observe the movement of residents. 

We  believe  that  this  increased  monitoring  through  our  Observations  Policy,  along  with  CCTV  cameras,  which  are 
monitored  by  the  managers,  and  additional  sensor  matts,  will  alert  staff  to  the  movement  of  residents  in  a  timely 
fashion and hopefully mitigate the risk of residents falling and coming to harm. 

Slips, Trips and Falls Policy 

All members of staff have now familiarised themselves with Our Slips, Trips and Falls Policy (attached). 

The policy identifies the duties and roles of Management and Staff members as follows: 

Management duties 

Managers and supervisors in the organisation have a duty to: 

 

 

 

 

ensure that all staff and volunteers are aware of and implement this policy 

ensure that an effective incident-reporting process is in place, that any slips, trips or falls, or near misses, are 
accurately reported and that regular scrutiny of accident reports is conducted to identify if slip, trip and fall 
hazards are being effectively controlled, that is, if reported incidents are reducing in number 

conduct regular audits of the management of slips, trips and falls within the home 

ensure that adequate and suitable training programmes are carried out which includes induction training on 
slips, trips and falls for new staff and falls prevention training for care staff. 

Staff duties 

Staff (and volunteers) in this organisation have a duty to: 

 

 

 

familiarise themselves with this policy 

report any slip, trip or falls incident or hazard to their manager or supervisor immediately 

conduct  any  activities  involving  electrical  equipment  in  a  careful  manner  to  minimise  the  dangers  from 
trailing wires, i.e. staff should always use the nearest socket available 

  practice good housekeeping procedures to prevent items and objects being left on the floor, especially in busy 

communal areas 

  attend appropriate training 

These  above  policies  will  hopefully  ensure  that  residents  are  not  left  unattended  or  unmonitored  and  the  risks  of 
residents slipping, tripping and falling is minimised in the future. We believe that residents are safe, they live in a safe 
environment  and  they  are  supported  by  dedicated  staff  who  are  appropriately  trained  and  are  capable  of  assisting 
residents in the event of a fall. 

 
 
 
 
 PINE VIEW CARE HOMES LTD 
Silver Birches 

Pine view 

418 – 420 Hinckley Road 

85 Lutterworth Road 

Leicester 
LE3 0WA 
OP, DE(4) 

Aylestone, Leicester 
LE2 8PJ 

OP, DE 

Concern 2 

In addition to the updated policies and changes we have made as outlined above, all staff have now undergone Slips, 
Trips and Falls training so they are aware of how to minimise the risk of residents falling and what to do in the event 
of a resident falling (see attached training log). This training included: 

  Causes and What to do 

  Preventing Future Falls 

  To gain an understanding of the common slip, trip and fall hazards 

  To gain an understanding of how best to prevent any future falls 

  To gain an understanding of the best practice and health and safety legislation surrounding slips, trips and falls 

  To gain an understanding of the appropriate action to take should someone fall 

  To gain an understanding of the potential consequences of a fall 

As stated above, CCTV cameras and additional sensor matts have been installed which alert staff to the movement of 
residents. 

Two stairgates – one at the top and one at the bottom of the staircase – have been installed to prevent residents from 
using the stairs without assistance in order to prevent falls and for their own safety (see attached pictures). 

We have also provided and continue to provide training to residents who are able to climb the stairs in relation to how 
to open and close the stairgates. Residents are assessed to ensure that they are able to do so and all residents climbing 
stairs are supervised by a staff member if the resident consents to this. 

In addition to the above, we will conduct regular training sessions for all staff to ensure that all members of staff are 
educated about the potential risks and harm from leaving residents unmonitored / unattended and their knowledge is 
kept up to date. 

We will also keep our policies under review to ensure that any positive changes to them will be made for the benefit, 
health and safety of our residents. 

Mindful  of  the  changes  that  we  have  implemented  above,  and  which  will  be  continuously  monitored  and  reviewed 
going forward, we believe that all of our residents are appropriately monitored, they are not left unattended and the 
environment that they live in is safe. 

We hope we have addressed and allayed the concerns of the Coroner in our response above. 

I  would  be  grateful  if  you  could  acknowledge  safe  receipt  of  my  letter  and,  if  you  have  any  queries,  please  do  not 
hesitate to contact me. 

I look forward to hearing from you. 

 
 
 
 
 PINE VIEW CARE HOMES LTD 
Silver Birches 

Pine view 

418 – 420 Hinckley Road 

85 Lutterworth Road 

Leicester 
LE3 0WA 
OP, DE(4) 

Aylestone, Leicester 
LE2 8PJ 

OP, DE 

Registered Manager 
Pine View Care Homes Ltd 

Enclosures: 

1) Photos of new stairgate x 2 
2) Staffing Hours Analysis for Pine View Care Homes Ltd 
3) Policy for Slips, Trips and Falls 
4) Observations Policy 
5) Log of Falls Training carried out by staff 
6) General Risk Assessments