The evidence before the court suggested that at Greatwood House, vulnerable residents including residents with dementia such as Mrs Douthwaite, be left unsupervised at times in communa areas by carers undertaking other tasks. The evidence before the court was that there are currently no clear written requirements in force across HC One'$ homes mandating the attendance of a colleague to monitor the communal area in question before leaving it unattended; The Risk of Falls Assessment Tool currently used across HC-One' $ homes was demonstrated in court to be unclear and susceptible to different interpretations: When asked about it in the course of her evidence, HC-One'$ Area Director was not aware as to whether or not this Assessment Tool had recently been benchmarked as against others used within the industry; Notwithstanding the fact Mrs Douthwaite had 3 falls over the course ofas many days in February 2018, HC One had not; asat the date of the Inquest; undertaken any investigation into the circumstances of these. The absence of any investigation by HC-One in this respect represents a missed opportunity to ascertain if any learning can be derived from these incidents for the benefit of other residents: