13 Feb 2019 Sophie Bennett · Prevention of Future Deaths report West London
View report summary
Concerns raised 20 Decision-making without firsthand knowledge of the service and residents View source Failure to control and maintain essential care documents View source Lack of a statutorily compliant registered manager View source Use of an auditor without appropriate clinical or mental-health qualifications View source Potential conflict of interest between external interests and RPFI View source Failure of the Board to retain control of significant service decisions View source Inadequate and non-objective post-death investigations View source Failure to consult staff and residents about substantial changes View source Unauthorised governance influence by a non-director and non-trustee View source Inadequate control of treatment and safety decisions View source Untrained and unqualified care staff View source Insufficient staffing levels View source Inadequate communication with agencies involved in resident care View source Inadequate duration of change-related audit View source Potential financial impropriety in the Lancaster Lodge lease View source Failure to keep and produce Board records, communications and contracts View source Lack of robust employment procedures View source Failure to manage the mental-health impact of sudden service changes View source Inadequate supervision and control of service changes View source Failure to report resident hospital admissions to the CQC View source See 17 more concerns
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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. The report was sent to Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Decision-making without firsthand knowledge of the service and residents
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Failure to control and maintain essential care documents
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Use of an auditor without appropriate clinical or mental-health qualifications
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Potential conflict of interest between external interests and RPFI
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Failure of the Board to retain control of significant service decisions
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Inadequate and non-objective post-death investigations
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Failure to consult staff and residents about substantial changes
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Unauthorised governance influence by a non-director and non-trustee
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Inadequate control of treatment and safety decisions
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Untrained and unqualified care staff
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing levels
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Inadequate communication with agencies involved in resident care
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Inadequate duration of change-related audit
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Potential financial impropriety in the Lancaster Lodge lease
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Failure to keep and produce Board records, communications and contracts
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Lack of robust employment procedures
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Failure to manage the mental-health impact of sudden service changes
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Inadequate supervision and control of service changes
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.
” 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 Richmond Companions International (RCI); that does not assign responsibility.
PFD Monitor interpretation Failure to report resident hospital admissions to the CQC
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.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations