PFD report

Marjorie Evelyne Keogh · Prevention of Future Deaths report

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Issued 4 Dec 2013•Leicester City and South Leicestershire

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
2

Of 2 recipients

Stated actions
7

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 assessment of suitability for occupying a first-floor room
    Part of recurring concern: Failure to assess room suitability and safety before placement
  2. Non-compliant staircase furniture strength at Scraptoft Court
  3. Regular absence of a manager at the home
    Part of recurring concern: Insufficient care home management capacity and oversight
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

    Complete work on the Scraptoft Court balustrade following the incident.

    Stated by MyMil Limited, T/a Scraptoft Court Care HomeStated completedThe respondent said that this action was complete when they made their response on 23 February 2014.
  2. Action

    Commission an independent surveyor to assess Scraptoft Court balustrade compliance and provide the report.

    Stated by MyMil Limited, T/a Scraptoft Court Care HomeStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2014.
  3. Action

    Continue reviewing the Commission’s registration approach, including whether to require evidence beyond provider declarations of compliance with building and planning regulations.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Staffing levels are based on residents’ needs, and current staffing exceeds guidance because fewer residents require nursing care.

    Stated by MyMil Limited, T/a Scraptoft Court Care HomeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 assessment of suitability for occupying a first-floor room

Wider context from the report

“(1) On the admission of Mrs Keogh and at subsequent reviews there did not appear to have been an assessment of her suitability to occupy a room on the first floor. Please confirm that such an assessment is now completed, and provide written evidence of such a requirement. ”

Is this part of a recurring concern?

Yes — Failure to assess room suitability and safety before placement.

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

Non-compliant staircase furniture strength at Scraptoft Court

Wider context from the report

“(4) Evidence indicated that the staircase furniture at Scraptoft Court did not meet strength requirements as stated in the plans for construction, nor British Standards and Building Regulations. I note that Scraptoft Court was constructed in the mid 1990s and shortly thereafter a further home was built called Syston Lodge. Is the staircase at that location compliant with the requirements referred to. ”

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

Regular absence of a manager at the home

Wider context from the report

“(2) Concerns were raised as to the staffing ratio to residents, and the lack of a manager at the home on that morning. The evidence indicated that as regards the latter point this was a regular occurrence. Please provide written evidence of current staffing requirements. ”

Is this part of a recurring concern?

Yes — Insufficient care home management capacity and oversight.

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

Inadequate staffing ratios to residents

Wider context from the report

“(2) Concerns were raised as to the staffing ratio to residents, and the lack of a manager at the home on that morning. The evidence indicated that as regards the latter point this was a regular occurrence. Please provide written evidence of current staffing requirements. ”

Is this part of a recurring concern?

Yes — Insufficient care-home staffing capacity for residents’ required care.

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

Conflicting falls-risk and manual-handling assessments for resident mobilisation

Wider context from the report

“(3) It seemed that there was evidence to indicate that there was conflict between the assessment of risk of falls and the assessment of manual handling, as to how serious a risk there was when Mrs Keogh mobilised. Please provide written evidence of how care plans and associated assessments are carried out. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unsafe moving and handling of patients.

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

Complete work on the Scraptoft Court balustrade following the incident.

Verbatim wording from the response

“4. We have not been able to confirm with Building Control at Charnwood Borough Council that the balustrade is compliant to the required standard.”

Source location

Response from My Mil Limited
Page 4 · response
Published 23 February 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

Commission an independent surveyor to assess Scraptoft Court balustrade compliance and provide the report.

Verbatim wording from the response

“4. We have not been able to confirm with Building Control at Charnwood Borough Council that the balustrade is compliant to the required standard.”

Source location

Response from My Mil Limited
Page 4 · response
Published 23 February 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

Continue reviewing the Commission’s registration approach, including whether to require evidence beyond provider declarations of compliance with building and planning regulations.

Verbatim wording from the response

“In terms of the Commission’s registration policies and procedures, we are currently reviewing our approach to registration. The contents of your Regulation 28 report helps to inform that review. During the course of considering our response to your Report we have consulted with the Head of Registration within the Commission. She has confirmed that particular and detailed consideration is being given to the extent to which the Commission should go beyond solely seeking a declaration at the point of registration from a provider that they are compliant with relevant Buildings Regulations and/or Planning regulations. That process of review is on-going.”

Source location

2013-0325-Response-by-Care-Quality-Commission
Page 5 · response
Published 23 February 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

Undertake building-regulation checks and seek compliance evidence for registration applications involving newly built locations or completed building works.

Verbatim wording from the response

“However, at this stage the Commission’s plan is to undertake checks and seek evidence to confirm a provider’s compliance with building regulations as part of a registration application where the provider seeks to accommodate people and where the location is newly built or where building works have been undertaken.”

Source location

2013-0325-Response-by-Care-Quality-Commission
Page 5 · response
Published 23 February 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

Staffing levels are based on residents’ needs, and current staffing exceeds guidance because fewer residents require nursing care.

Verbatim wording from the response

“2. There is no legislative prescriptive staffing level for care homes. Our staffing levels are based on needs of residents; we care for residents with residential care needs and nursing needs.”

Source location

Response from My Mil Limited
Page 2 · response
Published 23 February 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

For like-for-like registrations without risk information or proposed changes, provider declarations and the existing regulatory framework were considered sufficient without detailed building-compliance checks.

Verbatim wording from the response

“At the point of registration with the Commission in November 2010 the Commission did not specifically check whether Scraptoft Court was compliant with relevant Building Regulations. The provider declared that they were compliant with the Regulations and the provider indicated that no consideration was being given to changes either in relation to the activities that they were to provide, or to the location they were to be provided at, which would have resulted in a more detailed assessment of their registration. The registration for Scraptoft Court was in effect a ‘like for like’ transition from the previous regime to the new one. Scraptoft Court was adjudged compliant with the existing regulatory framework at the time of transition.”

Source location

2013-0325-Response-by-Care-Quality-Commission
Page 5 · response
Published 23 February 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

Local authority Building Control and Planning Departments are responsible for enforcing relevant building and planning regulations.

Verbatim wording from the response

“Under the current regulatory framework it remains the responsibility of providers to ensure that the premises in which they carry on a regulated activity is fully compliant with any relevant Buildings Regulations or British Standards. It is our interpretation”

Source location

2013-0325-Response-by-Care-Quality-Commission
Page 4 · response
Published 23 February 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

Providers are responsible for ensuring premises comply with relevant Building Regulations and British Standards.

Verbatim wording from the response

“When the Health and Social Care Act 2008 came into force the move away from prescriptive environmental requirements was further enshrined in the legislation. Establishments were no longer required to be specifically registered and there is no specific requirement in the Regulations concerning planning permission or building regulations. Nor indeed are fire, food safety or environmental health standards specifically and prescriptively incorporated into the Regulations.”

Source location

2013-0325-Response-by-Care-Quality-Commission
Page 4 · response
Published 23 February 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.3

  1. 1

    Review and change the care home’s documentation.

    Stated by MyMil Limited, T/a Scraptoft Court Care HomeStated completedThe respondent said that this action was complete when they made their response on 23 February 2014.
  2. 2

    Commission a structural engineer to assess Syston Lodge balustrading and make compliance recommendations.

    Stated by MyMil Limited, T/a Scraptoft Court Care HomeStated completedThe respondent said that this action was complete when they made their response on 23 February 2014.
  3. 3

    Share the report’s issue with inspectors and Commission managers, and use it to inform intelligence and policy processes.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 23 February 2014.

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 and change the care home’s documentation.

Verbatim wording from the response

“We have reviewed and changed all our care home documentation over the past 3 years and we have received a lot of positive feedback from professionals.”

Source location

Response from My Mil Limited
Page 4 · response
Published 23 February 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

Commission a structural engineer to assess Syston Lodge balustrading and make compliance recommendations.

Verbatim wording from the response

“1. In the matter of concerns (section 5, Reg. 28 report 4), it asks “Is the staircase at Syston Lodge compliant with the requirements referred to”.”

Source location

Response from My Mil Limited
Page 5 · response
Published 23 February 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

Share the report’s issue with inspectors and Commission managers, and use it to inform intelligence and policy processes.

Verbatim wording from the response

“Thank you for raising this issue with us. We intend to share it with inspectors and with other managers within the Commission as well as the report informing our intelligence and policy processes.”

Source location

2013-0325-Response-by-Care-Quality-Commission
Page 5 · response
Published 23 February 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