PFD report

Frederick Martin Gerard Boyd · Prevention of Future Deaths report

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Issued 2 May 2024•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
19

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Lack of a clear system or expectation for the quality of checks on unwell residents
  2. Limited documentation of key periods
  3. Limited senior-manager oversight of documentation quality
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. Action

    Request Mr Boyd’s care records and review the case under specific incident guidance.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
  2. Action

    Maintain clear protocols for identifying unwell residents and escalating concerns to district nursing teams and digital health coordinators.

    Stated by The Lakes Care Centre LimitedStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  3. Action

    Assess The Lakes Care Centre against relevant safety, effectiveness and leadership quality statements and evidence categories.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Regular checks and symptom management were provided overnight, although formal clinical observations were not recorded.

    Stated by The Lakes Care Centre LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a clear system or expectation for the quality of checks on unwell residents

Wider context from the report

“1. The inquest heard evidence that there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Limited documentation of key periods

Wider context from the report

“2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Limited senior-manager oversight of documentation quality

Wider context from the report

“2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unclear and poorly understood escalation system for unwell patients

Wider context from the report

“3. The evidence before the inquest indicated that the system for escalation where a patient was unwell was unclear and not understood by staff. ”

Is this part of a recurring concern?

Yes — Unreliable escalation policy for care concerns.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Limited staff understanding of the level of detail required in documentation

Wider context from the report

“2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

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

Request Mr Boyd’s care records and review the case under specific incident guidance.

Verbatim wording from the response

“We have reviewed all our records and cannot find that we received a statutory notification in relation to Mr Boyd’s death. Failure to provide statutory notifications in accordance with Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 is a criminal offence and we have written to the registered provider to request an explanation for their failure to notify and will review their response and may take further action. Subsequently we have contacted the service to request Mr Boyd’s care records so this case can be reviewed under our specific incident guidance.”

Source location

Response from Lakes Care Centre and CQC
Page 4 · response
Published 9 May 2024

Open published response

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

Maintain clear protocols for identifying unwell residents and escalating concerns to district nursing teams and digital health coordinators.

Verbatim wording from the response

“Our current Residential services, have clear protocols for knowing their residents ‘well’ status and how to identify if they are ‘unwell’, as well as how to escalate via local district nursing teams and Digital Health Care coordinators.”

Source location

Response from Lakes Care Centre and CQC
Page 10 · response
Published 9 May 2024

Open published response

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 The Lakes Care Centre against relevant safety, effectiveness and leadership quality statements and evidence categories.

Verbatim wording from the response

“On the 22 April 2024 CQC began an assessment of The Lakes Care Centre which included on-site and off-site processes. The decision to assess was following several concerns being raised at a MAC meeting in relation to ongoing safeguarding concerns, particularly those in relation to people with nursing needs. As a result, CQC undertook an”

Source location

Response from Lakes Care Centre and CQC
Page 4 · response
Published 9 May 2024

Open published response

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

Continue monitoring and assessing improvements in governance and oversight.

Verbatim wording from the response

“During our assessment we identified areas for improvement in terms of care plans, risk assessments and staff understanding of using Person Centred Software (PCS), the electronic care planning and recording system used at The Lakes Care Centre. The registered provider was already aware of this and was arranging additional training. As stated in our response to Point 1 there were also areas for improvement in relation to governance and oversight identified during this assessment, that we will continue to monitor and assess on an ongoing basis.”

Source location

Response from Lakes Care Centre and CQC
Page 5 · response
Published 9 May 2024

Open published response

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

Regular checks and symptom management were provided overnight, although formal clinical observations were not recorded.

Verbatim wording from the response

“On reading the care notes (completed by both care staff and nursing staff whilst on shift and supporting residents) it does show that regular patient checks were carried out and his symptom management was routinely supported through the night. I have attached a copy of the notes and highlighted the key times when observation and support was delivered and offered. It shows the nurse administering his prescribed medications and also pain relief ████████ after complaining of severe abdominal pain. He was continually observed during the night and these are recorded in his care notes. However, I accept that formal clinical observation (blood pressure, oxygen saturation and body temperature) was not recorded.”

Source location

Response from Lakes Care Centre and CQC
Page 9 · response
Published 9 May 2024

Open published response

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 assessment found no issues with escalation systems or staff understanding, and digital health services were generally used appropriately.

Verbatim wording from the response

“Inspectors did not identify any issues in respect of systems for escalation and staff understanding of this during our assessment and on-site activity. Feedback from the digital health service, the local clinical assessment service covering all care homes in Tameside, was that it was generally being used appropriately. Partner agencies felt things were improving overall and were complimentary about the staff working for the service who it was felt generally knew service user’s needs.”

Source location

Response from Lakes Care Centre and CQC
Page 6 · response
Published 9 May 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.15

  1. 1

    Deliver comprehensive employee training through team meetings, individual sessions, e-learning and face-to-face instruction.

    Stated by The Lakes Care Centre LimitedStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
  2. 2

    Reconfigure the workforce by appointing a new manager, Nominated Individual and leadership structure with clear accountability.

    Stated by The Lakes Care Centre LimitedStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  3. 3

    Hold weekly leadership meetings to share clinical progress and updates on required clinical protocols.

    Stated by The Lakes Care Centre LimitedStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
  4. 4

    Introduce an e-learning platform linking mandatory and developmental learning with policies, procedures and progress prompts.

    Stated by The Lakes Care Centre LimitedStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  5. 5

    Eliminate reliance on agency staff.

    Stated by The Lakes Care Centre LimitedStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  6. 6

    Review the provider’s explanation for the missing statutory notification and determine whether further action is needed.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  7. 7

    Rebuild working relationships with Infection Prevention and Contract Monitoring Teams to improve ongoing care quality and outcomes.

    Stated by The Lakes Care Centre LimitedStated in progressThe respondent said that this action was in progress when they made their response on 9 May 2024.
  8. 8

    Review progress against the provider’s action plan in line with regulatory processes.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  9. 9

    Require the registered provider to submit an action plan with completion timescales for identified actions.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  10. 10

    Review the impact of the provider’s management restructuring at the next assessment.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  11. 11

    Follow up with the home manager and seek their registration as registered manager.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
  12. 12

    Write to the registered provider for an explanation for failing to submit a statutory notification.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  13. 13

    De-register the nursing service so residents requiring nursing interventions receive care from district nurses.

    Stated by The Lakes Care Centre LimitedStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  14. 14

    Use the Single Assessment Framework and six evidence categories to assess providers and update ratings.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
  15. 15

    Appoint a Clinical Lead to oversee clinical matters and liaise with the manager on clinical protocols.

    Stated by The Lakes Care Centre LimitedStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Stopping nursing services means district nurses oversee nursing interventions, mitigating some risks because residents generally have less complex health conditions.

    Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Deliver comprehensive employee training through team meetings, individual sessions, e-learning and face-to-face instruction.

Verbatim wording from the response

“To expand on what we have undertaken so far:”

Source location

Response from Lakes Care Centre and CQC
Page 10 · response
Published 9 May 2024

Open published response

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

Reconfigure the workforce by appointing a new manager, Nominated Individual and leadership structure with clear accountability.

Verbatim wording from the response

“c) We have reviewed all employee performance against Job Descriptions and observation of practice and moved decisively to re-configure our workforce with people who are committed and able to deliver the excellent care and support we are striving for. This meant in practice a new manager being appointed, new Nominated Individual (CQC) and new leadership structure with clear lines of accountability and reporting responsibility.”

Source location

Response from Lakes Care Centre and CQC
Page 10 · response
Published 9 May 2024

Open published response

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

Hold weekly leadership meetings to share clinical progress and updates on required clinical protocols.

Verbatim wording from the response

“The current leadership team, appointed a Clinical Lead in October 2024 to lead on all matters Clinical. Part of this new role was to liaise with the Manager on all matters Clinical and to ensure that all the correct protocols were in place. We hold weekly Leadership meetings and as part of this process the Clinical Lead would share progress and updates on current Clinical matters and progress on the required clinical protocols. Regularly we were assured that all things required were in place.”

Source location

Response from Lakes Care Centre and CQC
Page 9 · response
Published 9 May 2024

Open published response

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

Introduce an e-learning platform linking mandatory and developmental learning with policies, procedures and progress prompts.

Verbatim wording from the response

“b) We are introducing (July 24) a new E Learning platform which will enable employees to access mandatory and developmental learning with associated policy and procedures attached as part of that learning. It will also provide much better visibility of employee learning progress and prompts employees and managers of the expectations in a timely manner to maximise attendance and outcomes.”

Source location

Response from Lakes Care Centre and CQC
Page 10 · response
Published 9 May 2024

Open published response

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

Eliminate reliance on agency staff.

Verbatim wording from the response

“e) Reduce our reliance on ‘agency staff’ to zero currently. This helps us be confident in our employees/workers skills and performance. In addition, we have more day-to-day confidence that our employees are following our Core Values in everyday practice.”

Source location

Response from Lakes Care Centre and CQC
Page 10 · response
Published 9 May 2024

Open published response

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

Review the provider’s explanation for the missing statutory notification and determine whether further action is needed.

Verbatim wording from the response

“We have reviewed all our records and cannot find that we received a statutory notification in relation to Mr Boyd’s death. Failure to provide statutory notifications in accordance with Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 is a criminal offence and we have written to the registered provider to request an explanation for their failure to notify and will review their response and may take further action. Subsequently we have contacted the service to request Mr Boyd’s care records so this case can be reviewed under our specific incident guidance.”

Source location

Response from Lakes Care Centre and CQC
Page 4 · response
Published 9 May 2024

Open published response

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

Rebuild working relationships with Infection Prevention and Contract Monitoring Teams to improve ongoing care quality and outcomes.

Verbatim wording from the response

“d) We have begun to nurture again our relationship with the local Infection Prevention Teams and Contract Monitoring Teams to ‘move’ forward on our performance on a day-to-day basis and improve the quality of care and support and outcomes for our residents.”

Source location

Response from Lakes Care Centre and CQC
Page 10 · response
Published 9 May 2024

Open published response

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

Review progress against the provider’s action plan in line with regulatory processes.

Verbatim wording from the response

“On publication of the report of our assessment we will require the registered provider to provide an action plan with clear timescales for completion of each action identified and will review progress against this action plan in line with our processes.”

Source location

Response from Lakes Care Centre and CQC
Page 5 · response
Published 9 May 2024

Open published response

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 the registered provider to submit an action plan with completion timescales for identified actions.

Verbatim wording from the response

“On publication of the report of our assessment we will require the registered provider to provide an action plan with clear timescales for completion of each action identified and will review progress against this action plan in line with our processes.”

Source location

Response from Lakes Care Centre and CQC
Page 5 · response
Published 9 May 2024

Open published response

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

Review the impact of the provider’s management restructuring at the next assessment.

Verbatim wording from the response

“The provider was in the process of restructuring the management arrangements for the two open units when we carried out our recent assessment. Of the two open units, one specialised in providing purely residential care and the other specialised in residential dementia care. This process had not been completed and we will review the impacts of this decision when we next assess the service.”

Source location

Response from Lakes Care Centre and CQC
Page 6 · response
Published 9 May 2024

Open published response

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

Follow up with the home manager and seek their registration as registered manager.

Verbatim wording from the response

“At the time of our visit there was no registered manager and although the home manager intended to register with the CQC, the application had not yet been successfully accepted. We will follow this up with the manager and seek to register them as soon as possible.”

Source location

Response from Lakes Care Centre and CQC
Page 6 · response
Published 9 May 2024

Open published response

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

Write to the registered provider for an explanation for failing to submit a statutory notification.

Verbatim wording from the response

“We have reviewed all our records and cannot find that we received a statutory notification in relation to Mr Boyd’s death. Failure to provide statutory notifications in accordance with Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 is a criminal offence and we have written to the registered provider to request an explanation for their failure to notify and will review their response and may take further action. Subsequently we have contacted the service to request Mr Boyd’s care records so this case can be reviewed under our specific incident guidance.”

Source location

Response from Lakes Care Centre and CQC
Page 4 · response
Published 9 May 2024

Open published response

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

De-register the nursing service so residents requiring nursing interventions receive care from district nurses.

Verbatim wording from the response

“At the time of Mr Boyd’s death, The Lakes Care Centre was operating as a nursing home, but the service has now ceased to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. This means that any service user requiring a nursing intervention will be under the care of the district nurses, which CQC believes mitigates some risks to the residents of this service as the service users being cared for will generally not have such complex health conditions.”

Source location

Response from Lakes Care Centre and CQC
Page 6 · response
Published 9 May 2024

Open published response

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

Use the Single Assessment Framework and six evidence categories to assess providers and update ratings.

Verbatim wording from the response

“On 6 February 2024 CQC’s Operations Network in the North region went live with our new Single Assessment Framework. This approach covers all sectors, service types and levels and the five key questions remain central to this approach. However, the previous key lines of enquiry (KLOEs) and prompts have been replaced with new ‘quality statements’. The quality are described as ‘we statements’ as they have been written from a provider’s perspective to help them understand what we expect of them. They draw on previous work developed with Think Local Act Personal (TLAP), National Voices and the Coalition for Collaborative Care on Making it Real. They set clear expectations of providers, based on people’s experiences and the standards of care they expect.”

Source location

Response from Lakes Care Centre and CQC
Page 3 · response
Published 9 May 2024

Open published response

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

Appoint a Clinical Lead to oversee clinical matters and liaise with the manager on clinical protocols.

Verbatim wording from the response

“The current leadership team, appointed a Clinical Lead in October 2024 to lead on all matters Clinical. Part of this new role was to liaise with the Manager on all matters Clinical and to ensure that all the correct protocols were in place. We hold weekly Leadership meetings and as part of this process the Clinical Lead would share progress and updates on current Clinical matters and progress on the required clinical protocols. Regularly we were assured that all things required were in place.”

Source location

Response from Lakes Care Centre and CQC
Page 9 · response
Published 9 May 2024

Open published response

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

Stopping nursing services means district nurses oversee nursing interventions, mitigating some risks because residents generally have less complex health conditions.

Verbatim wording from the response

“At the time of Mr Boyd’s death, The Lakes Care Centre was operating as a nursing home, but the service has now ceased to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. This means that any service user requiring a nursing intervention will be under the care of the district nurses, which CQC believes mitigates some risks to the residents of this service as the service users being cared for will generally not have such complex health conditions.”

Source location

Response from Lakes Care Centre and CQC
Page 6 · response
Published 9 May 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026