PFD report

Kenneth Cottam · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 7 Dec 2017•Derby and Derbyshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Lack of clear and robust policies and procedures for falls risk assessment and management
  2. Failure of staff to sufficiently understand falls policies and procedures for consistent and appropriate implementation
    Part of recurring concern: Inadequate control of falls risks
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

    Apply a documented falls-incident process with reports, management review, falls auditing and checks of required assessments and care records.

    Stated by Coxbench Hall LtdStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  2. Action

    Commence a high-falls-risk assessment after a resident experiences a second fall, using the appropriate assessment version.

    Stated by Coxbench Hall LtdStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.
  3. Action

    Disseminate falls policies and require staff policy acknowledgements on joining and annually.

    Stated by Coxbench Hall LtdStated completedThe respondent said that this action was complete when they made their response on 11 February 2018.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of clear and robust policies and procedures for falls risk assessment and management

Wider context from the report

“Having heard evidence from the management team at Coxbench Hall Care Home, the court was not reassured that there are clear and robust policies and procedures in place in relation to falls prevention and falls management, or that those policies and procedures are widely and consistently understood by staff. (1) The court was not reassured that there are clear and robust policies and procedures in place in relation to falls risk assessment and management. (2) The court was not reassured that staff had a sufficient understanding of the falls policies and procedures in place to enable them implement them consistently and appropriately. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of staff to sufficiently understand falls policies and procedures for consistent and appropriate implementation

Wider context from the report

“Having heard evidence from the management team at Coxbench Hall Care Home, the court was not reassured that there are clear and robust policies and procedures in place in relation to falls prevention and falls management, or that those policies and procedures are widely and consistently understood by staff. (1) The court was not reassured that there are clear and robust policies and procedures in place in relation to falls risk assessment and management. (2) The court was not reassured that staff had a sufficient understanding of the falls policies and procedures in place to enable them implement them consistently and appropriately. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Apply a documented falls-incident process with reports, management review, falls auditing and checks of required assessments and care records.

Verbatim wording from the response

“When there is an accident or incident, the staff who is ‘first on the scene’ completes an accident report form. This gets sent to the Office Manager, who checks that the General Manager has seen it – indicated by the General Manager’s signature on the form (obviously if she hasn’t, the form is sent to her). The Office Manager checks whether it is a matter that needs further investigation, or whether the matter has been dealt with and the Resident is all right so that the form can be filed. The General Manager also does this, but also ensures that the fall, if it was a fall, is noted on the Falls Audit form³ and all other procedures have been attended to; i.e. the following procedures which are carried out by Carers and Senior Carers:”

Source location

2017-0360-Response-by-Coxbench-Hall-Residentail-Home
Page 2 · response
Published 11 February 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Commence a high-falls-risk assessment after a resident experiences a second fall, using the appropriate assessment version.

Verbatim wording from the response

“Following Policy, a ‘Risk Assessment for when there is a high risk of falls’⁹ is commenced on the occasion of a second fall. There are two versions of this risk assessment as some Residents prefer that their falls mat is plugged in only at night for example, so the alternative risk assessment is then used.”

Source location

2017-0360-Response-by-Coxbench-Hall-Residentail-Home
Page 2 · response
Published 11 February 2018

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Disseminate falls policies and require staff policy acknowledgements on joining and annually.

Verbatim wording from the response

“Falls Policies².”

Source location

2017-0360-Response-by-Coxbench-Hall-Residentail-Home
Page 1 · response
Published 11 February 2018

Open published response
Back to top

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

Data last updated 7 September 2026