Sophie Bennett

The governance of Lancaster Lodge, and of the staff,and others, working there during the material period, was inadequate in the following respects: There was no "registered manager" who met the statutory criteria_ The staff were (despite RPFI's assertions to the contrary), generally, untrained, unqualified and too few in number: There were no, or no adequate, checks and controls by the staff; or by the acting manager; on the keeping of essential documents_ including risk May and put Very Jury assessments and progress notes, which were, in consequence , themselves inadequate , unreliable and misleading with corresponding risk to the safety of the residents_ The changes to which the determined circumstances refer were made following an audit by_ but: was qualified clinically, or in the field of mental health, to conduct that audit; the audit conducted by him (which led to the proposals for change) took only single day, which was grossly inadequate; there was no, or no adequate, consultation with the staff, or by the staff with the residents , regarding the substantial changes introduced, and to be made; and the changes were introduced at a "launch" with no, or no adequate regard to the negative impact of their sudden introduction on the mental stability of the residents. 5, Leadership and oversight by the Board of RPFI was grossly inadequate, in relation to: the need to have in place robust employment procedures; the matters listed under paragraphs 1 to 4 above; the appointments of the clinically unqualified and, later; the clinically unqualified art therapist as Clinical Lead, of a statutorily-approved registered manager, and of an adequate number of trained and qualified staff; supervision and control of the changes introduced at instigation; decisions made by the (unqualified) acting manager and staff in relation to the treatment to be given to the residents, and other steps required to meet their needs, and safety; communication with other agencies involved in the care of the residents; the keeping and production (including to the Court; for the purpose of the inquest) of the Board's own records, communications and contracts; and knowledge and performance of the Board's fundamental obligations_ including their duty of candour (not least in the Board having failed to fulfil its mandatory obligation to report to the CQC five instances of admission of Lancaster Lodge residents to hospital): Advice to the acting manager was provided byl the founder of