Recipient

Silver Birches

Pin Request correction

First report 26 Apr 2023•Latest report 26 Apr 2023

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Silver Birches linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Leicester City and South Leicestershire

    AI-generated summary

    Janet SMITH · 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

    Janet Smith, an 81-year-old woman with advanced dementia and ischaemic heart disease, sustained spinal fractures after an unwitnessed fall at her care home on 15 March 2022 and died on 22 March 2022 after deterioration and placement on palliative care. The principal concern was that insufficient staffing meant no carer was monitoring the lounge, allowing her to leave unattended, and that the provider had not done everything possible to mitigate the risk of harm or death from residents being left unmonitored.

    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 Silver Birches; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to monitor residents when carers attend competing care needs

    Wider context from the report

    “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. Accordingly, there remains a concern that the provider has not done everything possible to mitigate the risk of actual or potential harm including death. ”
    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 Silver Birches; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing capacity to meet competing resident care and monitoring needs

    Wider context from the report

    “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. Accordingly, there remains a concern that the provider has not done everything possible to mitigate the risk of actual or potential harm including death. ”
    Open source report
Back to top

Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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