PFD report

John Gwynfryn MORRIS · Prevention of Future Deaths report

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Issued 11 Nov 2013•Hertfordshire

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.

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Concerns
0

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
13

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.

No concerns are currently included for this report.

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.13

  1. 1

    Deliver mandatory Alzheimer’s Society-accredited dementia awareness training to all Commission staff.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 20 December 2013.
  2. 2

    Work with dementia organisations and local Healthwatch agencies to improve the Commission’s approach to regulating dementia care.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 December 2013.
  3. 3

    Assess staffing sufficiency for dementia care and use that assessment to shape regulatory approach and methodology improvements.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 December 2013.
  4. 4

    Produce and publish a national report describing dementia-care good practice, improvements, and consideration of staffing levels.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 December 2013.
  5. 5

    Undertake more out-of-hours inspections in the future.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 December 2013.
  6. 6

    Complete a themed inspection programme examining dementia care quality and transitions between hospitals and care homes.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 20 December 2013.
  7. 7

    Consider whether 24-hour provider compliance assessment should change as inspection methodology develops.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 20 December 2013.
  8. 8

    Complete a themed inspection programme examining dementia care quality and people’s experiences across hospitals and care homes.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 20 December 2013.
  9. 9

    Deliver mandatory dementia-awareness training to all Commission staff to strengthen dementia-related regulatory practice.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 20 December 2013.
  10. 10

    Work with dementia organisations to improve the Commission’s understanding and regulation of dementia care.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 December 2013.
  11. 11

    Publish a national report identifying dementia-care good practice and improvements across services, including staffing-level considerations.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 December 2013.
  12. 12

    Consider changes to inspection methodology to assess provider compliance over 24 hours, informed by staffing sufficiency for dementia care.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 20 December 2013.
  13. 13

    Undertake more out-of-hours inspections in the future.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 20 December 2013.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.5

  1. 1

    The night inspection found sufficient experienced staff and safety measures to meet residents’ needs and prevent wandering.

    Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    Inspections assess only selected care pathways, so they may not include people with complex night-time needs.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. 3

    Inspections can assess only selected care pathways, so they may not identify every person with complex nighttime needs.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  4. 4

    It cannot definitively determine whether two staff were sufficient because staffing needs depend on the home, residents, staff capabilities and duties.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  5. 5

    The inspection found sufficient nighttime staffing and safety measures to meet residents’ needs and prevent unsafe wandering.

    Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 mandatory Alzheimer’s Society-accredited dementia awareness training to all Commission staff.

Verbatim wording from the response

“3. The Commission has also sought to improve its own staff’s understanding of dementia by implementing Dementia Awareness Training. That training has been delivered by the Alzheimer’s Society and comprised mandatory training for all Commission staff to gain and consolidate knowledge, skills and support in order to appreciate better the impact of dementia on people’s experience of care and to incorporate that into our regulatory activities. That training has been delivered by internal trainers accredited by the Alzheimer’s Society and has had the following objectives:”

Source location

2013-0295R
Page 2 · response
Published 20 December 2013

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

Work with dementia organisations and local Healthwatch agencies to improve the Commission’s approach to regulating dementia care.

Verbatim wording from the response

“The Commission is also working with a number of dementia organisations to help inform and improve our approach to regulation by enhancing understanding of what works, what doesn’t work and how dementia care can be improved. Those organisations include the Dementia Action Alliance, Dementia Advocacy Network, Age UK, the Race Equality Foundation and local Healthwatch agencies. The results of that programme not only includes the publication of individual inspection reports but will also involve the production of a national report in May or June 2014 setting out the good practice that we have found together with improvements that can be made to dementia care across different services. Consideration of staffing levels will form part of that report.”

Source location

2013-0295R
Page 2 · response
Published 20 December 2013

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 staffing sufficiency for dementia care and use that assessment to shape regulatory approach and methodology improvements.

Verbatim wording from the response

“5. Regrettably, it is extremely difficult for the Commission to say definitively whether two members of staff were sufficient in numbers in a unit where people with dementia were resident in the circumstances of this very sad case. Those circumstances would include the layout of the home, the needs of the service users at the home at the time, the skills and experience of the members of staff that were on duty and what the staff that were on duty were required to do. Nevertheless, as we have endeavoured to set out above we are proposing to publish a national report in May or June 2014 which will set out the good practice that we have found together with improvements that can be made to dementia care across different services.”

Source location

2013-0295R
Page 4 · response
Published 20 December 2013

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

Produce and publish a national report describing dementia-care good practice, improvements, and consideration of staffing levels.

Verbatim wording from the response

“The Commission is also working with a number of dementia organisations to help inform and improve our approach to regulation by enhancing understanding of what works, what doesn’t work and how dementia care can be improved. Those organisations include the Dementia Action Alliance, Dementia Advocacy Network, Age UK, the Race Equality Foundation and local Healthwatch agencies. The results of that programme not only includes the publication of individual inspection reports but will also involve the production of a national report in May or June 2014 setting out the good practice that we have found together with improvements that can be made to dementia care across different services. Consideration of staffing levels will form part of that report.”

Source location

2013-0295R
Page 2 · response
Published 20 December 2013

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

Undertake more out-of-hours inspections in the future.

Verbatim wording from the response

“4. In terms of night time inspections the Commission does currently carry out inspections at night if we have a concern about the care being provided at night, and we will be undertaking more out-of-hours inspections in the future. Satisfying ourselves of the compliance of a service provider over 24 hours is something that is being given careful consideration and is likely to change as our methodology changes. Following the inquest into the tragic death of Mr Morris, and the concerns that were raised into care at night, an inspection was undertaken at Willowthorpe Care Home during the evening of 3 March 2014. The resultant report was published on 20 March 2014 and can be found on the Commission’s website, www.cqc.org.uk. For completeness we enclose a copy of that report to this letter. However, we also set out the relevant section dealing with staffing levels below:”

Source location

2013-0295R
Page 3 · response
Published 20 December 2013

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

Complete a themed inspection programme examining dementia care quality and transitions between hospitals and care homes.

Verbatim wording from the response

“2. The care provided to people that live with dementia is taken extremely seriously by the Commission. Greater focus is being given to the ways in which we can improve the Commission’s regulation of providers that offer care to people with dementia. As part of that development between December 2013 and February 2014 a themed programme of inspection on the quality of care for people with dementia took place. That programme focussed in particular on the experiences of people with dementia as they move between hospitals and care homes. The programme involved inspections of 150 hospitals and care homes in 22 different local authorities. Understanding the experience of people with dementia, their families and carers has been the main focus of the review.”

Source location

2013-0295R
Page 2 · response
Published 20 December 2013

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

Consider whether 24-hour provider compliance assessment should change as inspection methodology develops.

Verbatim wording from the response

“4. In terms of night time inspections the Commission does currently carry out inspections at night if we have a concern about the care being provided at night, and we will be undertaking more out-of-hours inspections in the future. Satisfying ourselves of the compliance of a service provider over 24 hours is something that is being given careful consideration and is likely to change as our methodology changes. Following the inquest into the tragic death of Mr Morris, and the concerns that were raised into care at night, an inspection was undertaken at Willowthorpe Care Home during the evening of 3 March 2014. The resultant report was published on 20 March 2014 and can be found on the Commission’s website, www.cqc.org.uk. For completeness we enclose a copy of that report to this letter. However, we also set out the relevant section dealing with staffing levels below:”

Source location

2013-0295R
Page 3 · response
Published 20 December 2013

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

Complete a themed inspection programme examining dementia care quality and people’s experiences across hospitals and care homes.

Verbatim wording from the response

“2. The care provided to people that live with dementia is taken extremely seriously by the Commission. Greater focus is being given to the ways in which we can improve the Commission’s regulation of providers that offer care to people with dementia. As part of that development between December 2013 and February 2014 a themed programme of inspection on the quality of care for people with dementia took place. That programme focussed in particular on the experiences of people with dementia as they move between hospitals and care homes. The programme involved inspections of 150 hospitals and care homes in 22 different local authorities. Understanding the experience of people with dementia, their families and carers has been the main focus of the review.”

Source location

2013-0295-Response-by-CQC
Page 2 · response
Published 20 December 2013

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

Deliver mandatory dementia-awareness training to all Commission staff to strengthen dementia-related regulatory practice.

Verbatim wording from the response

“3. The Commission has also sought to improve its own staff’s understanding of dementia by implementing Dementia Awareness Training. That training has been delivered by the Alzheimer’s Society and comprised mandatory training for all Commission staff to gain and consolidate knowledge, skills and support in order to appreciate better the impact of dementia on people’s experience of care and to incorporate that into our regulatory activities. That training has been delivered by internal trainers accredited by the Alzheimer’s Society and has had the following objectives:”

Source location

2013-0295-Response-by-CQC
Page 2 · response
Published 20 December 2013

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

Work with dementia organisations to improve the Commission’s understanding and regulation of dementia care.

Verbatim wording from the response

“The Commission is also working with a number of dementia organisations to help inform and improve our approach to regulation by enhancing understanding of what works, what doesn’t work and how dementia care can be improved. Those organisations include the Dementia Action Alliance, Dementia Advocacy Network, Age UK, the Race Equality Foundation and local Healthwatch agencies. The results of that programme not only includes the publication of individual inspection reports but will also involve the production of a national report in May or June 2014 setting out the good practice that we have found together with improvements that can be made to dementia care across different services. Consideration of staffing levels will form part of that report.”

Source location

2013-0295-Response-by-CQC
Page 2 · response
Published 20 December 2013

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

Publish a national report identifying dementia-care good practice and improvements across services, including staffing-level considerations.

Verbatim wording from the response

“The Commission is also working with a number of dementia organisations to help inform and improve our approach to regulation by enhancing understanding of what works, what doesn’t work and how dementia care can be improved. Those organisations include the Dementia Action Alliance, Dementia Advocacy Network, Age UK, the Race Equality Foundation and local Healthwatch agencies. The results of that programme not only includes the publication of individual inspection reports but will also involve the production of a national report in May or June 2014 setting out the good practice that we have found together with improvements that can be made to dementia care across different services. Consideration of staffing levels will form part of that report.”

Source location

2013-0295-Response-by-CQC
Page 2 · response
Published 20 December 2013

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

Consider changes to inspection methodology to assess provider compliance over 24 hours, informed by staffing sufficiency for dementia care.

Verbatim wording from the response

“4. In terms of night time inspections the Commission does currently carry out inspections at night if we have a concern about the care being provided at night, and we will be undertaking more out-of-hours inspections in the future. Satisfying ourselves of the compliance of a service provider over 24 hours is something that is being given careful consideration and is likely to change as our methodology changes. Following the inquest into the tragic death of Mr Morris, and the concerns that were raised into care at night, an inspection was undertaken at Willowthorpe Care Home during the evening of 3 March 2014. The resultant report was published on 20 March 2014 and can be found on the Commission’s website, www.cqc.org.uk. For completeness we enclose a copy of that report to this letter, where we also set out the relevant section dealing with staffing levels below:”

Source location

2013-0295-Response-by-CQC
Page 3 · response
Published 20 December 2013

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

Undertake more out-of-hours inspections in the future.

Verbatim wording from the response

“4. In terms of night time inspections the Commission does currently carry out inspections at night if we have a concern about the care being provided at night, and we will be undertaking more out-of-hours inspections in the future. Satisfying ourselves of the compliance of a service provider over 24 hours is something that is being given careful consideration and is likely to change as our methodology changes. Following the inquest into the tragic death of Mr Morris, and the concerns that were raised into care at night, an inspection was undertaken at Willowthorpe Care Home during the evening of 3 March 2014. The resultant report was published on 20 March 2014 and can be found on the Commission’s website, www.cqc.org.uk. For completeness we enclose a copy of that report to this letter, where we also set out the relevant section dealing with staffing levels below:”

Source location

2013-0295-Response-by-CQC
Page 3 · response
Published 20 December 2013

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 night inspection found sufficient experienced staff and safety measures to meet residents’ needs and prevent wandering.

Verbatim wording from the response

““The provider was meeting this standard.”

Source location

2013-0295R
Page 3 · response
Published 20 December 2013

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

Inspections assess only selected care pathways, so they may not include people with complex night-time needs.

Verbatim wording from the response

“1. The Commission agrees that the extra care that is required for people living with dementia is sometimes underestimated by providers. The Commission is also very conscious of the difficulty in assessing the staffing needs for people that live with dementia. For that reason when we are inspecting against the relevant staffing regulation¹ we do not only assess care plan records but also talk to staff as well as patients wherever possible. When we inspect care plan records we would expect to see a care plan for a person’s needs at night, and particularly if that person had been assessed as needing support at night. During the course of an inspection visit we are only able to assess and track a selection of people’s care pathways. Those does regrettably raise the”

Source location

2013-0295R
Page 1 · response
Published 20 December 2013

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

Inspections can assess only selected care pathways, so they may not identify every person with complex nighttime needs.

Verbatim wording from the response

“1. The Commission agrees that the extra care that is required for people living with dementia is sometimes underestimated by providers. The Commission is also very conscious of the difficulty in assessing the staffing needs for people that live with dementia. For that reason when we are inspecting against the relevant staffing regulation¹ we do not only assess care plan records but also talk to staff as well as patients wherever possible. When we inspect care plan records we would expect to see a care plan for a person’s needs at night, and particularly if that person had been assessed as needing support at night. During the course of an inspection visit we are only able to assess and track a selection of people’s care pathways. That does regrettably raise the”

Source location

2013-0295-Response-by-CQC
Page 1 · response
Published 20 December 2013

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

It cannot definitively determine whether two staff were sufficient because staffing needs depend on the home, residents, staff capabilities and duties.

Verbatim wording from the response

“5. Regrettably, it is extremely difficult for the Commission to say definitively whether two members of staff were sufficient in numbers in a unit where people with dementia were resident in the circumstances of this very sad case. Those circumstances would include the layout of the home, the needs of the service users at the home at the time, the skills and experience of the members of staff that were on duty and what the staff that were on duty were required to do. Nevertheless, as we have endeavoured to set out above we are proposing to publish a national report in May or June 2014 which will set out the good practice that we have found together with improvements that can be made to dementia care across different services.”

Source location

2013-0295-Response-by-CQC
Page 4 · response
Published 20 December 2013

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 inspection found sufficient nighttime staffing and safety measures to meet residents’ needs and prevent unsafe wandering.

Verbatim wording from the response

““The provider was meeting this standard.”

Source location

2013-0295-Response-by-CQC
Page 3 · response
Published 20 December 2013

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