John Gwynfryn MORRIS · Prevention of Future Deaths report

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Issued 11 Nov 2013•Hertfordshire

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an 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

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 raised0

    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. Care Quality Commission

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

    2. Care Quality Commission

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

    3. Care Quality Commission

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

    4. Care Quality Commission

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

    5. Care Quality Commission

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

    6. Care Quality Commission

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

    7. Care Quality Commission

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

    8. Care Quality Commission

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

    9. Care Quality Commission

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

    10. Care Quality Commission

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

    11. Care Quality Commission

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

    12. Care Quality Commission

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

    13. Care Quality Commission

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

    Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

    1. Care Quality Commission

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

      Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
    2. Care Quality Commission

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

      Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
    3. Care Quality Commission

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

      Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
    4. Care Quality Commission

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

      Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
    5. Care Quality Commission

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

      Disputes 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