PFD report

Mary Walker · Prevention of Future Deaths report

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Issued 21 Apr 2016•Manchester West

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
6

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 raised2

  1. Failure to record patients’ condition during night-time checks
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care recordsPart of recurring concern: Unreliable recording of required observations in care and custody
  2. Lack of clear procedures for Care Assistants escalating health concerns
    Part of recurring concern: Unreliable escalation by care staff for required medical attentionPart of recurring concern: Unreliable escalation policy for care concerns
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.3

  1. Action

    Undertake a comprehensive ratings inspection of Belong Wigan Care Village, including review of the provider’s response to the report findings.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.
  2. Action

    Provide refresher training to Belong Wigan staff on safe records management and accurate date-and-time recording.

    Stated by BelongStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.
  3. Action

    Remind Support Workers how to escalate health concerns and seek external professional advice through staff training, induction, supervision, reviews and audits.

    Stated by BelongStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.

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

  1. Position

    The provider’s response and inspection consideration were sufficient, so no written confirmation or further action evidence was requested.

    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 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 record patients’ condition during night-time checks

Wider context from the report

“(1) At the inquest there was no specific evidence about what was revealed in the night time checks that had been carried out upon the deceased. There was a global summary stating the times at which checks had been carried out but there was no information as to what the patient’s condition was at the checks. This procedure requires review. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records; Unreliable recording of required observations in care and custody.

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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 procedures for Care Assistants escalating health concerns

Wider context from the report

“(2) During the inquest there was a lack of clarity in relation to the procedures to be followed by Care Assistants when they wanted to escalate health concerns. This system requires review. ”

Is this part of a recurring concern?

Yes — Unreliable escalation by care staff for required medical attention; Unreliable escalation policy for care concerns.

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

Undertake a comprehensive ratings inspection of Belong Wigan Care Village, including review of the provider’s response to the report findings.

Verbatim wording from the response

“Following receipt of this Report we held a management review meeting to look at the information we held in relation to this case. At this meeting we took the decision to:”

Source location

2016-0150-Response-by-Care-Quality-Commission
Page 1 · response
Published 21 April 2016

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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

Provide refresher training to Belong Wigan staff on safe records management and accurate date-and-time recording.

Verbatim wording from the response

“• Refresher training has been provided by the management team to all staff in Belong Wigan, on the ‘Safe management of records’ policy and procedures with an emphasis on the importance of accurate recording of progress against dates and times.”

Source location

2016-0150-Response-by-Belong
Page 1 · response
Published 21 April 2016

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

Remind Support Workers how to escalate health concerns and seek external professional advice through staff training, induction, supervision, reviews and audits.

Verbatim wording from the response

“• All Support Workers have been reminded of the correct procedures to follow and how to seek advice from outside professionals for non-nursing customers in their care, when they need to escalate health concerns. This is incorporated into the care practice training for all staff, to include staff induction, supervision, life plan review and audit.”

Source location

2016-0150-Response-by-Belong
Page 2 · response
Published 21 April 2016

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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 provider’s response and inspection consideration were sufficient, so no written confirmation or further action evidence was requested.

Verbatim wording from the response

“We noted the response provided to you by the registered provider, CLS Care Services Limited known as Belong on 27 April 2016. In light of this response it was not felt necessary for CQC to contact the registered provider to request written confirmation and”

Source location

2016-0150-Response-by-Care-Quality-Commission
Page 1 · response
Published 21 April 2016

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

Following inspection and document review, no further investigation into the death or regulated activities was considered necessary.

Verbatim wording from the response

“Thank you for providing us with disclosure during the Coronial investigation. We can confirm that following our inspection and a review of these documents we do not intend to undertake further investigations in relation to the death of Mary Walker or the provision of regulated activities by CLS Care Services Limited.”

Source location

2016-0150-Response-by-Care-Quality-Commission
Page 2 · response
Published 21 April 2016

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

    Publish the final report of the inspection when the factual accuracy process permits.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 21 April 2016.
  2. 2

    Require nurses to record professional advice and directions in customers’ individual records.

    Stated by BelongStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.
  3. 3

    Meet with senior staff to identify uses for an approved audit tool supporting safe and correct procedures.

    Stated by BelongStated completedThe respondent said that this action was complete when they made their response on 21 April 2016.

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 the final report of the inspection when the factual accuracy process permits.

Verbatim wording from the response

“As a result of our inspection we have provisionally rated the service as ‘good’ subject to the factual accuracy process. The report of our inspection is currently in draft form.”

Source location

2016-0150-Response-by-Care-Quality-Commission
Page 2 · response
Published 21 April 2016

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 nurses to record professional advice and directions in customers’ individual records.

Verbatim wording from the response

“• Nurses are required to follow policy and procedure and will record any professional advice and direction provided within the customers’ individual records.”

Source location

2016-0150-Response-by-Belong
Page 1 · response
Published 21 April 2016

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

Meet with senior staff to identify uses for an approved audit tool supporting safe and correct procedures.

Verbatim wording from the response

“• Meetings have been held with all senior staff to identify the uses of an approved audit tool to ensure sure safe and correct procedures are being followed.”

Source location

2016-0150-Response-by-Belong
Page 1 · response
Published 21 April 2016

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