PFD report

JAMES DWAYNE CLARKE · Prevention of Future Deaths report

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Issued 10 Sep 2014•Black Country

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

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

Concerns raised3

  1. Failure to carry out required overnight checks
    Part of recurring concern: Failure to carry out required overnight checksPart of recurring concern: Unreliable patient observation arrangements
  2. Lack of clear instructions defining required overnight checks
    Part of recurring concern: Failure to carry out required overnight checks
  3. Lack of practical training for carers
    Part of recurring concern: Inadequate training and competence assurance for carers providing care
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

    Ensure the coroner’s report is noted and informs the provider’s next ratings inspection, including examination of processes and training.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 10 September 2014.
  2. Action

    Adopt the Health and Social Care Act 2008 fundamental standards, including requirements concerning personalised, safe and competent care.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 10 September 2014.
  3. Action

    Develop inspection processes using longer team-based inspections, consistent key lines of enquiry and service ratings.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 10 September 2014.

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

Failure to carry out required overnight checks

Wider context from the report

“My concerns are that two carers having been employed, the expectation was that one would be with James constantly. The written instructions from the care home said “Call is to check James throughout the night and carry out tracheotomy care/suction if necessary”. Whilst there was no further explanation of what “throughout the night” meant, the evidence I had was that the carers sat in a room on the other side of the corridor to James’ bedroom, they were watching television and playing computer games and talking, they did not check him between 1.a.m and 4.a.m. and again did not check him between 4.10 a.m and 6.a.m. and only then because his peg feed alarm sounded. He was found dead at that stage. The carers had had theoretical training, but no practical training had been given to them by the care company who employed them. Their employers were Complete Care Services, which is the trading name of C.C.S. Central Limited of West Midlands House, Gypsy Lane, Willenhall, Wolverhampton, West Midlands WV13 2HA and I was told that the company are registered with the Care Quality Commission. I was concerned that the standard of care provided for James was seriously lacking and that if that standard of care was reflected in the care given to others, to whom C.C.S. provided services, then there may be a risk to other members of the public. ”

Is this part of a recurring concern?

Yes — Failure to carry out required overnight checks; Unreliable patient observation arrangements.

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

Lack of clear instructions defining required overnight checks

Wider context from the report

“My concerns are that two carers having been employed, the expectation was that one would be with James constantly. The written instructions from the care home said “Call is to check James throughout the night and carry out tracheotomy care/suction if necessary”. Whilst there was no further explanation of what “throughout the night” meant, the evidence I had was that the carers sat in a room on the other side of the corridor to James’ bedroom, they were watching television and playing computer games and talking, they did not check him between 1.a.m and 4.a.m. and again did not check him between 4.10 a.m and 6.a.m. and only then because his peg feed alarm sounded. He was found dead at that stage. The carers had had theoretical training, but no practical training had been given to them by the care company who employed them. Their employers were Complete Care Services, which is the trading name of C.C.S. Central Limited of West Midlands House, Gypsy Lane, Willenhall, Wolverhampton, West Midlands WV13 2HA and I was told that the company are registered with the Care Quality Commission. I was concerned that the standard of care provided for James was seriously lacking and that if that standard of care was reflected in the care given to others, to whom C.C.S. provided services, then there may be a risk to other members of the public. ”

Is this part of a recurring concern?

Yes — Failure to carry out required overnight checks.

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

Lack of practical training for carers

Wider context from the report

“My concerns are that two carers having been employed, the expectation was that one would be with James constantly. The written instructions from the care home said “Call is to check James throughout the night and carry out tracheotomy care/suction if necessary”. Whilst there was no further explanation of what “throughout the night” meant, the evidence I had was that the carers sat in a room on the other side of the corridor to James’ bedroom, they were watching television and playing computer games and talking, they did not check him between 1.a.m and 4.a.m. and again did not check him between 4.10 a.m and 6.a.m. and only then because his peg feed alarm sounded. He was found dead at that stage. The carers had had theoretical training, but no practical training had been given to them by the care company who employed them. Their employers were Complete Care Services, which is the trading name of C.C.S. Central Limited of West Midlands House, Gypsy Lane, Willenhall, Wolverhampton, West Midlands WV13 2HA and I was told that the company are registered with the Care Quality Commission. I was concerned that the standard of care provided for James was seriously lacking and that if that standard of care was reflected in the care given to others, to whom C.C.S. provided services, then there may be a risk to other members of the public. ”

Is this part of a recurring concern?

Yes — Inadequate training and competence assurance for carers providing care.

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

Ensure the coroner’s report is noted and informs the provider’s next ratings inspection, including examination of processes and training.

Verbatim wording from the response

“We will ensure that your report is noted and informs the next ratings inspection that takes place of Complete Care Services; although the information is now a little dated the issues are well worth a further examination of their processes and training provision.”

Source location

2014-0398-Response-by-Care-Quality-Commission
Page 3 · response
Published 10 September 2014

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

Adopt the Health and Social Care Act 2008 fundamental standards, including requirements concerning personalised, safe and competent care.

Verbatim wording from the response

“In April 2015 CQC will adopt the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, known as the “fundamental standards”. The changes in the regulations have emerged from the Robert Francis recommendations that there should be very obvious standards below which care must not fall. Regulation 9 will ensure that people receive care and treatment that is personalised for them and meets their needs; Regulation 12 is intended to prevent people from receiving unsafe care and treatment, and prevent avoidable harm or risk of harm. These regulations in particular will require providers to ensure that care is planned and delivered in a way that makes it crystal clear to care staff what is required of them, and that staff are experienced, trained and competent in the areas where they are providing that care.”

Source location

2014-0398-Response-by-Care-Quality-Commission
Page 3 · response
Published 10 September 2014

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

Develop inspection processes using longer team-based inspections, consistent key lines of enquiry and service ratings.

Verbatim wording from the response

“In implementing the new fundamental standards, our inspection processes have been developed. We will conduct longer, more in-depth inspections with a team approach designed to “get under the skin” of care services. We have key lines of enquiry which are explored and reported on consistently. Each care service will be rated either Outstanding, Good, Requires Improvement or Inadequate. We will continue to use our enforcement powers where services do not deliver safe services.”

Source location

2014-0398-Response-by-Care-Quality-Commission
Page 3 · response
Published 10 September 2014

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

Carry out an unannounced responsive inspection of the care provider against safeguarding, risk, welfare and complaints requirements.

Verbatim wording from the response

“In terms of actions that we have undertaken, in May 2011 we carried out a responsive inspection unannounced. This was the service’s first inspection under the Health and Social Care Act 2008. This would have focused on the issues considered relevant at the point of inspection and any information of concern that we held. We inspected against four of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These were:”

Source location

2014-0398-Response-by-Care-Quality-Commission
Page 2 · response
Published 10 September 2014

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.1

  1. 1

    Inspect the provider’s Stafford Street location and assess compliance with the applicable regulations.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 10 September 2014.

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

  1. 1

    No further responsive inspections or regulatory action were considered necessary because subsequent inspections found no sufficient concerns or shortfalls.

    Stated by Care Quality CommissionNo action considered necessaryThe respondent said that 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

Inspect the provider’s Stafford Street location and assess compliance with the applicable regulations.

Verbatim wording from the response

“Since that time, we have inspected the organisation’s location at Stafford Street and found it to be compliant with all regulations inspected. There have been no concerns sufficient to trigger further responsive inspections or regulatory action.”

Source location

2014-0398-Response-by-Care-Quality-Commission
Page 2 · response
Published 10 September 2014

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

No further responsive inspections or regulatory action were considered necessary because subsequent inspections found no sufficient concerns or shortfalls.

Verbatim wording from the response

“Since that time, we have inspected the organisation’s location at Stafford Street and found it to be compliant with all regulations inspected. There have been no concerns sufficient to trigger further responsive inspections or regulatory action.”

Source location

2014-0398-Response-by-Care-Quality-Commission
Page 2 · response
Published 10 September 2014

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