Lakes Care Centre and CQC
Other
Action Taken
The Lakes Care Centre has ceased to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. The CQC is following up with the manager to register them as soon as possible. (AI summary)
View full response
Dear HM Senior Coroner Alison Mutch OBE,
Prevention of future death report following inquest into the death of Frederick Martin Gerard Boyd Thank you for sending CQC a copy of the prevention of future death report issued following the sad death of Frederick Martin Gerard Boyd.
We note the legal requirement upon the Care Quality Commission to respond to your report within 56 days, by the 27 June 2024 and would like to thank you again for agreeing to an extension for response until 26 July 2024. The registered provider of The Lakes Care Centre is The Lakes Care Centre Limited. They have been registered with CQC as a service provider since 25 August 2023.
The provider’s location, The Lakes Care Centre is located . At the time of Mr Boyd’s death, the provider was registered for the regulated activities: ‘Accommodation for persons who require nursing or personal care’ and ‘Treatment of disease, disorder or injury’.
The Lakes Care Centre does not currently have a manager who is registered with CQC to oversee and manage the delivery of the regulated activities at this location, in line with the condition imposed on this provider’s registration for this location, stating that they must HSCA Further Information
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have a registered manager in post. The current home manager, submitted applications to register with CQC on 25 February 2024 and 6 March 2024. These applications have been rejected by CQC’s registration team as being incomplete and a new application has not yet been received or processed by CQC. The previous registered manager, , was registered with CQC between 25 August 2023 and 13 October 2023 to manage the regulated activities at The Lakes Care Centre under the current provider The Lakes Care Centre Limited. The role of the CQC & Inspection methodology The role of the Care Quality Commission (CQC) as an independent regulator is to register health and adult social care service providers in England and to assess/inspect whether or not the fundamental standards set out in the Health and Social Care Act 2008, and amendments, are being met.
The regulatory approach used during previous inspections of The Lakes Care Centre considered five key questions. They asked if services were Safe; Effective; Caring; Responsive; and Well Led. Inspectors used a series of key lines of enquiry (KLOEs) and prompts to seek and corroborate evidence and reassurance of how the provider performed against characteristics of ratings and how risks to service users were identified, assessed and mitigated.
The regulatory framework includes providers being required to meet fundamental standards of care; the standards below which care must never fall. We provide guidance to providers on how they can meet these standards (Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).
On 6 February 2024 CQC’s Operations Network in the North region went live with our new Single Assessment Framework. This approach covers all sectors, service types and levels and the five key questions remain central to this approach. However, the previous key lines of enquiry (KLOEs) and prompts have been replaced with new ‘quality statements’. The quality are described as ‘we statements’ as they have been written from a provider’s perspective to help them understand what we expect of them. They draw on previous work developed with Think Local Act Personal (TLAP), National Voices and the Coalition for Collaborative Care on Making it Real. They set clear expectations of providers, based on people’s experiences and the standards of care they expect. We have introduced six new evidence categories to organise information under the statements; these are feedback from people, feedback from staff and leaders, feedback from partners, our observations, processes and outcomes. This approach will allow CQC to use a range of information to assess providers flexibly and frequently, collect evidence on an ongoing basis and update ratings at any time; tailor our assessment to different types of providers and services; score evidence to make our judgements more structured and consistent; use site visits and data and insight to A2
3
gather evidence to assess quality and produce shorter and simpler reports, showing the most up-to-date assessment.
Background
We have reviewed all our records and cannot find that we received a statutory notification in relation to Mr Boyd’s death. Failure to provide statutory notifications in accordance with Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 is a criminal offence and we have written to the registered provider to request an explanation for their failure to notify and will review their response and may take further action. Subsequently we have contacted the service to request Mr Boyd’s care records so this case can be reviewed under our specific incident guidance.
Regulatory History
The Lakes Care Centre was registered with CQC under the current provider, The Lakes Care Centre Limited on 25 August 2023. Prior to this the service was managed by Blackcliffe Limited.
Under the previous provider, Blackcliffe Limited, there had been poor compliance with relevant regulations and CQC had taken numerous enforcement actions to drive improvement which had ultimately led to the service being rated ‘Inadequate’ overall and the provider going into administration. An inspection undertaken in February 2023 (published 13 April 2023) identified some improvements had been made to the service delivered. It was subsequently rated ‘requires improvement’ overall with conditions placed on the registration. This allowed the administrators to proceed with a sale of The Lakes Care Centre as a going concern. The Lakes Care Centre Limited commenced operating the home under a licence to manage agreement on 18 July 2023 and the sale of the home was completed on 22 September 2023.
The Lakes Care Centre has been in a multiagency concern (MAC) process led by Tameside MBC since 23 May 2022. This process brings together key stakeholders including commissioners, health services, CQC and the provider to oversee and support the provider and to share information both positive and negative about the service delivered and progress towards improvements in performance.
On the 22 April 2024 CQC began an assessment of The Lakes Care Centre which included on-site and off-site processes. The decision to assess was following several concerns being raised at a MAC meeting in relation to ongoing safeguarding concerns, particularly those in relation to people with nursing needs. As a result, CQC undertook an A3
4
assessment looking at all quality statements and evidence categories relating to the key questions ‘Is the service safe?’ ‘Is the service effective?’ and ‘Is the service well led?’ At the time the assessment commenced The Lakes Care Centre had stopped delivering the regulated activity of ‘Treatment of Disease, disorder and injury’ and all people with nursing needs had been transferred to alternative placements by 19 April 2024.
Matters of concern
1. The inquest heard evidence that there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell.
During our assessment of The Lakes Care Centre, inspectors spoke with people who used the service and their families. Families were happy and people all felt confident that staff would promptly seek support from other healthcare professionals when this was required. However, shortfalls in record keeping and systems of oversight meant that people were placed at the risk of avoidable harm. Staff were not consistently receiving sufficient training and support in their role. There were shortfalls in the training records and the systems in place for oversight were not effective to allow for easy identification of gaps in training. Not all staff had received regular supervision and there were no clear systems of oversight of supervision to ensure staff were suitably supported. We identified breaches of Regulation 12 (Safe care and treatment), Regulation 18 (Staffing) and Regulation 17 (Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
On publication of the report of our assessment we will require the registered provider to provide an action plan with clear timescales for completion of each action identified and will review progress against this action plan in line with our processes.
2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited.
During our assessment we identified areas for improvement in terms of care plans, risk assessments and staff understanding of using Person Centred Software (PCS), the electronic care planning and recording system used at The Lakes Care Centre. The registered provider was already aware of this and was arranging additional training. As stated in our response to Point 1 there were also areas for improvement in relation to governance and oversight identified during this assessment, that we will continue to monitor and assess on an ongoing basis.
3. The evidence before the inquest indicated that the system for escalation where a patient was unwell was unclear and not understood by staff. A4
5
Inspectors did not identify any issues in respect of systems for escalation and staff understanding of this during our assessment and on-site activity. Feedback from the digital health service, the local clinical assessment service covering all care homes in Tameside, was that it was generally being used appropriately. Partner agencies felt things were improving overall and were complimentary about the staff working for the service who it was felt generally knew service user’s needs.
At the time of Mr Boyd’s death, The Lakes Care Centre was operating as a nursing home, but the service has now ceased to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. This means that any service user requiring a nursing intervention will be under the care of the district nurses, which CQC believes mitigates some risks to the residents of this service as the service users being cared for will generally not have such complex health conditions.
Since the provider has registered to manage the regulated activities at the location there have been a number of changes in the management team and structure of the service. There had been concerns about the service and the level and speed of improvement being made. Partner agencies raised concerns that information had not always been escalated effectively and statutory notifications which services are required to send to CQC were not always completed. As stated above, we have written to the registered provider regarding this matter and will review their response to determine appropriate action.
The provider was in the process of restructuring the management arrangements for the two open units when we carried out our recent assessment. Of the two open units, one specialised in providing purely residential care and the other specialised in residential dementia care. This process had not been completed and we will review the impacts of this decision when we next assess the service.
At the time of our visit there was no registered manager and although the home manager intended to register with the CQC, the application had not yet been successfully accepted. We will follow this up with the manager and seek to register them as soon as possible.
Prevention of future death report following inquest into the death of Frederick Martin Gerard Boyd Thank you for sending CQC a copy of the prevention of future death report issued following the sad death of Frederick Martin Gerard Boyd.
We note the legal requirement upon the Care Quality Commission to respond to your report within 56 days, by the 27 June 2024 and would like to thank you again for agreeing to an extension for response until 26 July 2024. The registered provider of The Lakes Care Centre is The Lakes Care Centre Limited. They have been registered with CQC as a service provider since 25 August 2023.
The provider’s location, The Lakes Care Centre is located . At the time of Mr Boyd’s death, the provider was registered for the regulated activities: ‘Accommodation for persons who require nursing or personal care’ and ‘Treatment of disease, disorder or injury’.
The Lakes Care Centre does not currently have a manager who is registered with CQC to oversee and manage the delivery of the regulated activities at this location, in line with the condition imposed on this provider’s registration for this location, stating that they must HSCA Further Information
A1
2
have a registered manager in post. The current home manager, submitted applications to register with CQC on 25 February 2024 and 6 March 2024. These applications have been rejected by CQC’s registration team as being incomplete and a new application has not yet been received or processed by CQC. The previous registered manager, , was registered with CQC between 25 August 2023 and 13 October 2023 to manage the regulated activities at The Lakes Care Centre under the current provider The Lakes Care Centre Limited. The role of the CQC & Inspection methodology The role of the Care Quality Commission (CQC) as an independent regulator is to register health and adult social care service providers in England and to assess/inspect whether or not the fundamental standards set out in the Health and Social Care Act 2008, and amendments, are being met.
The regulatory approach used during previous inspections of The Lakes Care Centre considered five key questions. They asked if services were Safe; Effective; Caring; Responsive; and Well Led. Inspectors used a series of key lines of enquiry (KLOEs) and prompts to seek and corroborate evidence and reassurance of how the provider performed against characteristics of ratings and how risks to service users were identified, assessed and mitigated.
The regulatory framework includes providers being required to meet fundamental standards of care; the standards below which care must never fall. We provide guidance to providers on how they can meet these standards (Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).
On 6 February 2024 CQC’s Operations Network in the North region went live with our new Single Assessment Framework. This approach covers all sectors, service types and levels and the five key questions remain central to this approach. However, the previous key lines of enquiry (KLOEs) and prompts have been replaced with new ‘quality statements’. The quality are described as ‘we statements’ as they have been written from a provider’s perspective to help them understand what we expect of them. They draw on previous work developed with Think Local Act Personal (TLAP), National Voices and the Coalition for Collaborative Care on Making it Real. They set clear expectations of providers, based on people’s experiences and the standards of care they expect. We have introduced six new evidence categories to organise information under the statements; these are feedback from people, feedback from staff and leaders, feedback from partners, our observations, processes and outcomes. This approach will allow CQC to use a range of information to assess providers flexibly and frequently, collect evidence on an ongoing basis and update ratings at any time; tailor our assessment to different types of providers and services; score evidence to make our judgements more structured and consistent; use site visits and data and insight to A2
3
gather evidence to assess quality and produce shorter and simpler reports, showing the most up-to-date assessment.
Background
We have reviewed all our records and cannot find that we received a statutory notification in relation to Mr Boyd’s death. Failure to provide statutory notifications in accordance with Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 is a criminal offence and we have written to the registered provider to request an explanation for their failure to notify and will review their response and may take further action. Subsequently we have contacted the service to request Mr Boyd’s care records so this case can be reviewed under our specific incident guidance.
Regulatory History
The Lakes Care Centre was registered with CQC under the current provider, The Lakes Care Centre Limited on 25 August 2023. Prior to this the service was managed by Blackcliffe Limited.
Under the previous provider, Blackcliffe Limited, there had been poor compliance with relevant regulations and CQC had taken numerous enforcement actions to drive improvement which had ultimately led to the service being rated ‘Inadequate’ overall and the provider going into administration. An inspection undertaken in February 2023 (published 13 April 2023) identified some improvements had been made to the service delivered. It was subsequently rated ‘requires improvement’ overall with conditions placed on the registration. This allowed the administrators to proceed with a sale of The Lakes Care Centre as a going concern. The Lakes Care Centre Limited commenced operating the home under a licence to manage agreement on 18 July 2023 and the sale of the home was completed on 22 September 2023.
The Lakes Care Centre has been in a multiagency concern (MAC) process led by Tameside MBC since 23 May 2022. This process brings together key stakeholders including commissioners, health services, CQC and the provider to oversee and support the provider and to share information both positive and negative about the service delivered and progress towards improvements in performance.
On the 22 April 2024 CQC began an assessment of The Lakes Care Centre which included on-site and off-site processes. The decision to assess was following several concerns being raised at a MAC meeting in relation to ongoing safeguarding concerns, particularly those in relation to people with nursing needs. As a result, CQC undertook an A3
4
assessment looking at all quality statements and evidence categories relating to the key questions ‘Is the service safe?’ ‘Is the service effective?’ and ‘Is the service well led?’ At the time the assessment commenced The Lakes Care Centre had stopped delivering the regulated activity of ‘Treatment of Disease, disorder and injury’ and all people with nursing needs had been transferred to alternative placements by 19 April 2024.
Matters of concern
1. The inquest heard evidence that there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell.
During our assessment of The Lakes Care Centre, inspectors spoke with people who used the service and their families. Families were happy and people all felt confident that staff would promptly seek support from other healthcare professionals when this was required. However, shortfalls in record keeping and systems of oversight meant that people were placed at the risk of avoidable harm. Staff were not consistently receiving sufficient training and support in their role. There were shortfalls in the training records and the systems in place for oversight were not effective to allow for easy identification of gaps in training. Not all staff had received regular supervision and there were no clear systems of oversight of supervision to ensure staff were suitably supported. We identified breaches of Regulation 12 (Safe care and treatment), Regulation 18 (Staffing) and Regulation 17 (Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
On publication of the report of our assessment we will require the registered provider to provide an action plan with clear timescales for completion of each action identified and will review progress against this action plan in line with our processes.
2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited.
During our assessment we identified areas for improvement in terms of care plans, risk assessments and staff understanding of using Person Centred Software (PCS), the electronic care planning and recording system used at The Lakes Care Centre. The registered provider was already aware of this and was arranging additional training. As stated in our response to Point 1 there were also areas for improvement in relation to governance and oversight identified during this assessment, that we will continue to monitor and assess on an ongoing basis.
3. The evidence before the inquest indicated that the system for escalation where a patient was unwell was unclear and not understood by staff. A4
5
Inspectors did not identify any issues in respect of systems for escalation and staff understanding of this during our assessment and on-site activity. Feedback from the digital health service, the local clinical assessment service covering all care homes in Tameside, was that it was generally being used appropriately. Partner agencies felt things were improving overall and were complimentary about the staff working for the service who it was felt generally knew service user’s needs.
At the time of Mr Boyd’s death, The Lakes Care Centre was operating as a nursing home, but the service has now ceased to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. This means that any service user requiring a nursing intervention will be under the care of the district nurses, which CQC believes mitigates some risks to the residents of this service as the service users being cared for will generally not have such complex health conditions.
Since the provider has registered to manage the regulated activities at the location there have been a number of changes in the management team and structure of the service. There had been concerns about the service and the level and speed of improvement being made. Partner agencies raised concerns that information had not always been escalated effectively and statutory notifications which services are required to send to CQC were not always completed. As stated above, we have written to the registered provider regarding this matter and will review their response to determine appropriate action.
The provider was in the process of restructuring the management arrangements for the two open units when we carried out our recent assessment. Of the two open units, one specialised in providing purely residential care and the other specialised in residential dementia care. This process had not been completed and we will review the impacts of this decision when we next assess the service.
At the time of our visit there was no registered manager and although the home manager intended to register with the CQC, the application had not yet been successfully accepted. We will follow this up with the manager and seek to register them as soon as possible.