18 Jun 2025 Margaret Elizabeth DOUGLAS · Prevention of Future Deaths report Cheshire
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Concerns raised 3 Failure of one-to-one carers to understand individuals’ complex needs View source Failure of one-to-one carers to communicate effectively with individuals who have speech difficulties View source Failure to ensure provision of required one-to-one care before accepting care responsibilities View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 7
Action
Include agency-worker induction in routine internal monitoring through a documented monthly area-manager audit.
View source
Action
Provide written care descriptions and relevant care-plan information during handovers to irregular staff, alongside verbal handover and electronic access.
View source
Action
Remind managers to escalate refusals of required one-to-one care to Head Office and the oversight team.
View source
Action
Provide clinical nurse and director support to managers managing residents with complex needs.
View source
Action
Require staff engaged by the service to complete the IELTS exam before working on site.
View source
Action
Assess and provide interim one-to-one care using the organisation’s workforce while external funding is pursued.
View source
Action
Assess overseas agency workers’ spoken and written English at each shift and exclude those with inadequate proficiency from working on site.
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AI-generated summary
Margaret Elizabeth DOUGLAS · 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
Margaret Elizabeth Douglas suffered recurrent falls, a subdural haemorrhage, worsening stroke symptoms and increasing frailty while receiving care, and died after a further deterioration at Holcroft Grange. Concerns included accepting her into care despite being unable to provide the required one-to-one supervision, and using carers whose understanding of her complex needs and ability to communicate effectively were questioned, particularly given her risk of aspiration.
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× 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 Minster Care Management Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of one-to-one carers to understand individuals’ complex needs
Wider context from the report “ii) In the course of the Inquest I heard evidence from the individual who was caring for Elizabeth on the morning of her death and in the course of that evidence it became apparent that the carer had little understanding of Elizabeth’s needs and had difficulty communicating and understanding information in English. The evidence given by those at Holcroft Grange was that they outsourced the provision of the one to one carers to a company, '1st Care 4 U Ltd' who had been approved for use by their parent company 'Minster Care Group'. At the time the care was provided, it was known by those responsible for sourcing the care, that there were difficulties with Elizabeth’s communication and complex needs. This evidence gives rise to significant concerns in respect of the ability of those providing one to one care to understand an individual’s complex needs and their ability to communicate with those who themselves have difficulties with their speech. The concerns were heightened in the context of this case given that Elizabeth was at high risk of aspiration and if carers are unable to understand the complexities of an individual’s needs and communicate effectively with them, it poses a risk to their life.
” 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 Minster Care Management Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of one-to-one carers to communicate effectively with individuals who have speech difficulties
Wider context from the report “ii) In the course of the Inquest I heard evidence from the individual who was caring for Elizabeth on the morning of her death and in the course of that evidence it became apparent that the carer had little understanding of Elizabeth’s needs and had difficulty communicating and understanding information in English . The evidence given by those at Holcroft Grange was that they outsourced the provision of the one to one carers to a company, '1st Care 4 U Ltd' who had been approved for use by their parent company 'Minster Care Group'. At the time the care was provided, it was known by those responsible for sourcing the care, that there were difficulties with Elizabeth’s communication and complex needs. This evidence gives rise to significant concerns in respect of the ability of those providing one to one care to understand an individual’s complex needs and their ability to communicate with those who themselves have difficulties with their speech . The concerns were heightened in the context of this case given that Elizabeth was at high risk of aspiration and if carers are unable to understand the complexities of an individual’s needs and communicate effectively with them , it poses a risk to their life.
” 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 Minster Care Management Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure provision of required one-to-one care before accepting care responsibilities
Wider context from the report “i) In the course of the Inquest I heard evidence that by the 5th September 2024, Holcroft Grange had already identified that they were unable to meet Elizabeth's needs, considering that she required one to one care. Despite being aware that they were unable to meet Elizabeth's needs and that they were unable to provide one to one care , Holcroft Grange accepted Elizabeth back into their care , following which she suffered a further fall. Agreeing to provide care for an individual in circumstances where it is known that the level of care that person requires to keep them safe cannot be provided , creates a risk that future deaths could occur as a consequence of inadequate care and supervision.
” Open source report
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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 Include agency-worker induction in routine internal monitoring through a documented monthly area-manager audit.
Verbatim wording from the response “2) Our induction policy for agency workers will now form part of our compliance test undertaken by our routine internal monitoring teams. A monthly audit is carried out by area managers and the induction policy for agency workers will form a specific section within the audit documentation. This will provide assurances to our monitoring team that all agency staff have had sufficient opportunity to engage and read the relevant care plans for each resident they are caring for. Each agency carer will also have an induction through their own agency, before they are given an induction to the site and to the residents to be cared for, which will include time allocated to read specific care plans.” Source location Response from Minster Care Group
Open published response
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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 Provide written care descriptions and relevant care-plan information during handovers to irregular staff, alongside verbal handover and electronic access.
Verbatim wording from the response “3) Handover of care between staff will be enhanced to ensure that any irregular staff ie Agency carers, have a written description of the issues and conditions that a person may exhibit. In addition to verbal handovers from the relevant staff members, written descriptions of the care plans will now be provided at the start of the shift. Information contained in the handover is also provided on handheld electronic devices that are given to all staff, and this information can also be easily updated at any given time.” Source location Response from Minster Care Group
Open published response
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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 Remind managers to escalate refusals of required one-to-one care to Head Office and the oversight team.
Verbatim wording from the response “3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance & support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.” Source location Response from Minster Care Group
Open published response
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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 Provide clinical nurse and director support to managers managing residents with complex needs.
Verbatim wording from the response “We understand that costs should not be a factor which determines the necessity of providing 1-1 care. Within the Croftwood Care portfolio of homes, any manager can contact me to seek support with navigating the difficulties in securing funding for clients such as Elizabeth.” Source location Response from Minster Care Group
Open published response
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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 Require staff engaged by the service to complete the IELTS exam before working on site.
Verbatim wording from the response “In order to ensure that any staff engaged by Holcroft Grange have an appropriate understanding of residents’ care needs, we ensure that they have completed the International English Language Test (IELTS) exam. This forms part of our introductory checklists and paperwork prior to staff members working on our premises.” Source location Response from Minster Care Group
Open published response
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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 Assess and provide interim one-to-one care using the organisation’s workforce while external funding is pursued.
Verbatim wording from the response “3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance & support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.” Source location Response from Minster Care Group
Open published response
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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 Assess overseas agency workers’ spoken and written English at each shift and exclude those with inadequate proficiency from working on site.
Verbatim wording from the response “1) Our organisation will ensure that all overseas workers that attend our services via agencies have a competent understanding of the English language, both spoken and written. This will now be assessed by the person in charge of each shift to ensure that the command of the English language is good. Where it is deemed “inadequate” the staff member will not be allowed to work on site.” Source location Response from Minster Care Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The suggestion that providers can fund one-to-one care and reclaim costs from local authorities does not reflect the provider’s experience.
Verbatim wording from the response “I note in court, that the local authority stated that as a provider we could have put a 1-1 in place and then claimed back the monies later down the line. However, this suggestion is just not my experience or our company’s experience of working with local authorities and I can highlight several cases whereby we are pursuing funds for such cases via the courts.” Source location Response from Minster Care Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation One-to-one care cannot continue indefinitely without local-authority funding; if funding is refused, the resident may need to leave the home.
Verbatim wording from the response “3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance & support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.” Source location Response from Minster Care Group
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations