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 Pine view Silver Birches 418 – 420 Hinckley Road 85 Lutterworth Road Leicester Aylestone, Leicester LE3 0WA LE2 8PJ OP, DE(4) 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 Pine view Silver Birches 418 – 420 Hinckley Road 85 Lutterworth Road Leicester Aylestone, Leicester LE3 0WA LE2 8PJ OP, DE(4) 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 Pine view Silver Birches 418 – 420 Hinckley Road 85 Lutterworth Road Leicester Aylestone, Leicester LE3 0WA LE2 8PJ OP, DE(4) 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 Pine view Silver Birches 418 – 420 Hinckley Road 85 Lutterworth Road Leicester Aylestone, Leicester LE3 0WA LE2 8PJ OP, DE(4) 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 Pine view Silver Birches 418 – 420 Hinckley Road 85 Lutterworth Road Leicester Aylestone, Leicester LE3 0WA LE2 8PJ OP, DE(4) 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