Recurring concern

Failure to ensure care-home managers meet statutory registration requirements

First to latest report 7 Oct 2016 — 13 Feb 2019

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
0

What this concern includes

Includes failures to appoint, retain or verify a registered care-home manager who meets applicable statutory registration criteria, including use of an unregistered manager where registration is required.

What is not included
  • Excludes general care-home management shortages, absences or weak oversight where statutory registration of the manager is not the identified unsafe condition.
  • Excludes failures concerning frontline care staffing, training or qualifications unless they specifically concern the statutory registration status of the care-home manager.
  • Excludes clinical qualification deficiencies that are not relevant to the manager's statutory registration requirements.
  • Excludes broader provider governance, financial management or care-quality failures where compliant manager registration is not the shared concern.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. West London

    AI-generated summary

    Sophie Bennett · 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

    Sophie Elizabeth Alice Bennett died at Kingston Hospital from injuries caused by applying a ligature at Lancaster Lodge, a care home operated by RPFI. The Jury identified concerns about inadequate governance, staffing, training, documentation, leadership and oversight, and found contributory errors or omissions in risk management, including failure to follow advice to take Sophie to A&E, inadequate observation and poor control of access to ligature items.

    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.

    PFD Monitor interpretation

    Lack of a statutorily compliant registered manager

    Wider context from the report

    “The governance of Lancaster Lodge, and of the staff, and others, working there during the material period, was inadequate in the following respects: 1. There was no “registered manager” who met the statutory criteria. 2. The staff were (despite RPFI’s assertions to the contrary), generally, untrained, unqualified and too few in number. 3. 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 assessments and progress notes, which were, in consequence, themselves inadequate, unreliable and misleading - with corresponding risk to the safety of the residents. 4. The changes to which the determined circumstances refer were made following an audit by ████████ out: • ████████ was not 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 a 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). 6. Advice to the acting manager was provided by ████████ - the founder of RPFI - and significant decisions regarding Lancaster Lodge and the residents, were made by her (in each case as a “consultant” to the Board, rather than by the Board of RPFI), and were followed by RPFI staff, when: • ████████ was neither a director, nor a Trustee, of RPFI (one Board member describing her role as “somewhat ambiguous”, and the evidence suggesting that she was a “shadow director”); and • ████████ had never visited Lancaster Lodge, and had never met (or had any knowledge, firsthand, knowledge of the residents). 7. The possibility of there being: • a conflict between the interests of ████████ (who, it appears, may have had a personal or family connection with the ownership of Lancaster Lodge) and those of RPFI itself; and • financial impropriety, in relation to the lease under which Lancaster Lodge was (it seems) held. 8. The post-death investigations carried out on behalf of RPFI: • were inadequate, verging on self-serving, and not objective; and • give rise to concerns as to their veracity and accuracy (the authorship of certain supposedly contemporaneous statements being denied by the staff member whose name appears on them as their maker). 9. The facts that: • a director and trustee of RPFI is also the Chairman of RCI; and • ████████ appears to have some family connection with the owner of RCI’s premises give rise to concerns in relation to RCI corresponding to those itemised under paragraphs 5 to 7 above. ”

    Source location

    Sophie Bennett · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Norman Arthur BEARD · 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

    Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.

    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.

    PFD Monitor interpretation

    Use of an unregistered home manager

    Wider context from the report

    “(1) The home known as Daisy Bank Cheddle has now closed however there are three other care homes which remain under that same ownership of ████████ and managed by the same Chief Executive, Mr Tee. (2) Poor management and absences of management staff was evident during the inquest. The home manager was not registered and was not medically qualified. ”

    Source location

    Norman Arthur BEARD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026