Cole Valley Care Limited

Private and voluntary organisations · Private limited company

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First report 8 Feb 2019•Latest report 29 Mar 2021

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Cole Valley Care Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

29 Mar2021
Birmingham and Solihull
Concerns raised5
1. Failure to record preceding resident falls in resident files
2. Failure to comply with court orders to supply relevant evidence
3. Misleading recording of resident observation intervals
1. Failure to formally review falls risk assessments and care policies after a resident death
2. Failure to update residents' falls risk assessments
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Raymond Alfred POWELL · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Raymond Alfred POWELL became increasingly frail, moved into Cole Valley Nursing Home, and suffered falls on 3 November 2020 that caused an acute subdural haematoma. He later developed an infection and seizure and died on 5 December 2020. Concerns included failures to record a preceding fall, update his falls risk assessment, accurately document observations, formally review the circumstances, and comply with court orders for evidence, creating an ongoing risk to other residents.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to record preceding resident falls in resident files
Wider context from the report
“(1) The nursing home manager confirmed that a preceding fall (most likely on 15 October) had not been recorded anywhere within Raymond's file and this was the first time she was aware of a preceding fall (Raymond's family's evidence was they were told during a visit on 15 October, and nursing home carer ████████ confirmed there was a preceding fall a few weeks earlier). The nursing home manager was unable to explain why this preceding fall had not been recorded anywhere. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to comply with court orders to supply relevant evidence
Wider context from the report
“3. The nursing home failed to comply with repeated court orders to supply relevant evidence. On 14 December the nursing home manager was ordered to supply evidence by 18 January. With no response the court order was extended on 8 February to 10 February. One day late, on 11 February, the nursing home manager supplied the witness statements but no documents. On 16 February the nursing home manager was ordered to supply the documents by 23 February. With no response the nursing home manager was served with a schedule 5 notice containing a penal notice to supply the documents by 18 March. In breach of the schedule 5 notice, on 22 March the nursing home manager supplied some but not all documents. I did not accept the reported problem with an email account as justifying the needed failure to comply with court orders for 3 months. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Misleading recording of resident observation intervals
Wider context from the report
“(3) On 3 November staff were observing Raymond every 15 minutes however they only endorsed the 30 minute boxes on his observation log meaning it was misleading. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to formally review falls risk assessments and care policies after a resident death
Wider context from the report
“1. The nursing home manager confirmed that Cole Valley Nursing Home had not conducted an internal investigation into the circumstances of Raymond's death. The rationale was "no foul play or inappropriate behaviour was suspected. Staff acted appropriately and phoned 999". I am concerned that it was not thought necessary to formally review the appropriateness of Raymond's falls risk assessment and the nursing home's policies and procedures to see what lessons could be learned to improve the safety of other residents. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to update residents' falls risk assessments
Wider context from the report
“(2) The nursing home manager in her written report to the Coroner stated that Raymond's falls risk assessment had been updated. However, the evidence revealed in fact the falls risk assessment had been created on 30 September upon Raymond's arrival, and had never been updated. Raymond's named nurse should have reviewed and updated it at the end of October with the preceding fall on 15 October being a key factor in the updated assessment. The nursing home manager was unable to explain why the named nurse did not update the falls risk assessment as expected. ”
Open source report
8 Feb2019
Birmingham and Solihull
Concerns raised10
1. Risk of vulnerable residents falling out of wheelchairs
2. Vulnerability of residents to falls-related harm
3. Inadequate assurance of wheelchair-fall risk management
1. Undated and unsigned falls risk management and assessment documents
2. Failure to investigate restraint-device availability and use inside the nursing home
3. Reliance on staff presence to prevent falls
4. Inconsistent use of wheelchair lap belts across locations
5. Inadequate post-incident investigation and organisational learning
6. Inadequate completion of falls risk assessments
7. Reliance on staff intervention during wheelchair falls
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Jean Mary Cutler · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jean Mary Cutler had severe dementia, osteoporosis and no independent mobility, and was at high risk of falling. On 5 October 2018 she fell from her wheelchair at Cole Valley Nursing Home, sustaining a fractured left femur, and died there on 18 October 2018. Concerns included inconsistent use of lap belts, reliance on staff intervention despite understaffing, and inadequate post-incident investigation and falls risk assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Risk of vulnerable residents falling out of wheelchairs
Wider context from the report
“4. However, the inconsistency of using lap belts outside the nursing home, but no similar restraint device when inside remains. The reliance on a member of staff being able to intervene in time continues despite the incident on 5/10/18 revealing the inadequacy of this as a safety measure. The nursing home has not investigated the availability and use of restraint devices inside the nursing home. My on-going concern is that there remains a risk of vulnerable residents falling out of wheelchairs. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Vulnerability of residents to falls-related harm
Wider context from the report
“1. Cole Valley Nursing Home is run by a private company and cares for up to 45 residents who are vulnerable due to their age and physical and mental health issues. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Inadequate assurance of wheelchair-fall risk management
Wider context from the report
“3. I heard evidence that following the incident the Care Quality Commission and Clinical Commission Group had requested from the nursing home copies of revised risk management documents. In my opinion this has led to the nursing home being given the impression their management of residents from falling out of wheelchairs is adequate. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Undated and unsigned falls risk management and assessment documents
Wider context from the report
“6. The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls. My on-going concern is that the falls risk assessment has not being adequately completed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to investigate restraint-device availability and use inside the nursing home
Wider context from the report
“4. However, the inconsistency of using lap belts outside the nursing home, but no similar restraint device when inside remains. The reliance on a member of staff being able to intervene in time continues despite the incident on 5/10/18 revealing the inadequacy of this as a safety measure. The nursing home has not investigated the availability and use of restraint devices inside the nursing home. My on-going concern is that there remains a risk of vulnerable residents falling out of wheelchairs. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Reliance on staff presence to prevent falls
Wider context from the report
“6. The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls. My on-going concern is that the falls risk assessment has not being adequately completed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Inconsistent use of wheelchair lap belts across locations
Wider context from the report
“2. Pre-incident, the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk; Outside the nursing home a lap belt would be attached to the wheelchair. Whereas inside the nursing home no lap belt was used. A member of staff was expected to be able to intervene when a resident was in the process of falling. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Inadequate post-incident investigation and organisational learning
Wider context from the report
“5. The nursing home’s internal investigation recognised as root causes of the incident a lack of internal knowledge and guidance, that the home had been through a hard time recently and it had impacted on the staff, that care plans did not give correct guidance to staff, and that management was unstable. However, the only post-action event listed was an ‘incident debrief’. The nursing home manager agreed when given evidence that the action plan would have been more effective if it had included a review of the falls risk assessment, the viability of restraint devices being used both outside and inside, and a review of whether staff numbers were adequate. My on-going concern is that the post incident investigation was inadequate and lessons have not been learned. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Inadequate completion of falls risk assessments
Wider context from the report
“6. The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls. My on-going concern is that the falls risk assessment has not being adequately completed. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Reliance on staff intervention during wheelchair falls
Wider context from the report
“2. Pre-incident, the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk; Outside the nursing home a lap belt would be attached to the wheelchair. Whereas inside the nursing home no lap belt was used. A member of staff was expected to be able to intervene when a resident was in the process of falling. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure to record preceding resident falls in resident files

Failure to comply with court orders to supply relevant evidence

Misleading recording of resident observation intervals

Failure to formally review falls risk assessments and care policies after a resident death

Failure to update residents' falls risk assessments

Concerns raised10

Risk of vulnerable residents falling out of wheelchairs

Vulnerability of residents to falls-related harm

Inadequate assurance of wheelchair-fall risk management

Undated and unsigned falls risk management and assessment documents

Failure to investigate restraint-device availability and use inside the nursing home

Reliance on staff presence to prevent falls

Inconsistent use of wheelchair lap belts across locations

Inadequate post-incident investigation and organisational learning

Inadequate completion of falls risk assessments

Reliance on staff intervention during wheelchair falls