PFD report

Gunapathyammah Ranganathan · Prevention of Future Deaths report

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Issued 13 Mar 2023•West London

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
22

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. Lack of adequate training and shadowing for new carers
    Part of recurring concern: Inadequate training and competence assurance for carers providing care
  2. Failure to provide direct supervision during service-user mobilisation
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.12

  1. Action

    Use the new field-shadowing form to document shadowing activity.

    Stated by Lean on Me Community Care Services LtdStated completedThe respondent said that this action was complete when they made their response on 13 March 2023.
  2. Action

    Source staff training from a vetted preferred provider aligned with Skills for Care and CQC standards.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
  3. Action

    Support care workers without RQF qualifications to enrol on RQF courses.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.

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 adequate training and shadowing for new carers

Wider context from the report

“There was little evidence before the court that the new carer had received any or any adequate training or shadowing experience. The new carer could not be deemed to be competent at mobilising a service user with a Zimmer frame as there was no evidence that she had done so. Lean on Me care agency was said to not currently be trading, but the company and web site remain live and therefore could recommence work in the care sector. The court requires confirmation of training schedules and policies, together with shadowing policies for new carers with no previous experience or training and confirmation that steps have been taken to avoid the situation that arose in this case, when a service user who should have been under direct supervision at all times when mobilising was unattended, and sustained a fatal head injury when she fell. ”

Is this part of a recurring concern?

Yes — Inadequate training and competence assurance for carers providing 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

Failure to provide direct supervision during service-user mobilisation

Wider context from the report

“There was little evidence before the court that the new carer had received any or any adequate training or shadowing experience. The new carer could not be deemed to be competent at mobilising a service user with a Zimmer frame as there was no evidence that she had done so. Lean on Me care agency was said to not currently be trading, but the company and web site remain live and therefore could recommence work in the care sector. The court requires confirmation of training schedules and policies, together with shadowing policies for new carers with no previous experience or training and confirmation that steps have been taken to avoid the situation that arose in this case, when a service user who should have been under direct supervision at all times when mobilising was unattended, and sustained a fatal head injury when she fell. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Use the new field-shadowing form to document shadowing activity.

Verbatim wording from the response

“As we do not have any service users whose care needs involve regulation 9 Regulated Activities. we are attaching to you a blank copy of our new FIELD SHADOWING FORM.”

Source location

Response from Lean on Me Care Agency
Page 5 · response
Published 13 March 2023

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

Source staff training from a vetted preferred provider aligned with Skills for Care and CQC standards.

Verbatim wording from the response

“In future, all our staff training needs will be sourced out to a Training Agency that has been suitably vetted by my Local Authority as their preferred training providers, so that the training needs of Lean on Me are fully in line with Skills for Care and CQC Standards of good practice.”

Source location

Response from Lean on Me Care Agency
Page 3 · response
Published 13 March 2023

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

Support care workers without RQF qualifications to enrol on RQF courses.

Verbatim wording from the response

“continue as a care worker or not. For those care workers who have not acquired RQF, they too will be supported to enrol in RQF courses.”

Source location

Response from Lean on Me Care Agency
Page 5 · response
Published 13 March 2023

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 and implement policies and procedures covering shadowing records and competency observations.

Verbatim wording from the response

“• New policies and procedures to be developed, including records for shadowing and competency observations.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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 vetted new staff and management to complete Level 1 and Level 2 induction training and follow the service’s policies and procedures.

Verbatim wording from the response

“You will also notice a breakdown of the Health and Social Care training courses which I have identified to be beneficial to all Lean On Me care workers, including the Management Team; regardless of their previous experience, qualifications acquired in care or in other professions. All applicants who have been successfully vetted and who have accepted our offer of employment, must attend all grassroots training courses Level 1 and Level 2 Induction Training. All staff must work within Lean On Me’s Policies and Procedures guidelines, which are in line with CQC standards of good practice, at office level and in the field.”

Source location

Response from Lean on Me Care Agency
Page 3 · response
Published 13 March 2023

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 and implement new staff training and assessment systems.

Verbatim wording from the response

“• New training and assessment systems will be considered and implemented.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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

Implement ongoing quality monitoring of staff training.

Verbatim wording from the response

“• An ongoing quality monitoring of training is to be implemented.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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

Provide strength-based and train-the-trainer courses so supervisory and management staff can support field care workers.

Verbatim wording from the response

“Coordinators, Quality assurance officers and Field care workers, must all, again, undergo the training courses starting at level 1 Induction training, and level 2 Care Award. This will be followed by further training in “STRENGTH BASED” COURSES, including “TRAIN THE TRAINER”, so that our field supervisors, care coordinators, managers, quality assurance officers all have the knowledge required to support field care workers when they require additional support from the office staff.”

Source location

Response from Lean on Me Care Agency
Page 4 · response
Published 13 March 2023

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

Add safe Zimmer-frame transfers and emergency responses to moving-and-handling knowledge tests.

Verbatim wording from the response

“• Moving and handling component to specifically include in testing knowledge of safe Zimmer frame transfers, and how to respond to emergencies.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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

Recruit seven experienced management personnel, including field care supervisors.

Verbatim wording from the response

“I have recently recruited 7 management personnel. The 7 applicants already have acquired more than 5 years’ experience working in Health and Social Care. One has Leadership and Management qualifications in care, and has been earmarked as a future Manager, because she has worked as a Registered Manager for a large Care provider in the past. Another possible manager has Adult Nursing qualifications from Massachusetts USA, and is currently doing UK NMC adaptation. He has also acquired other qualifications in the USA: a Bachelor’s degree in public health and an NBA master’s degree in business administration. I have two field care supervisors with over 10-years previous care experience, including specialist training courses acquired when they worked in other Care provider organisations.”

Source location

Response from Lean on Me Care Agency
Page 4 · response
Published 13 March 2023

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

Redevelop senior-staff training, including the new-carer manual-handling competency test.

Verbatim wording from the response

“• Senior staff training in all areas to be redeveloped, including importance of “new carer test” in Manual Handling.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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 recruiting care workers and field supervisors to provide competent field shadowing and performance appraisal.

Verbatim wording from the response

“This being said, we are still recruiting all who are interested to work with Lean on Me - Care workers and Field Care Supervisors. Our goal is to have a good number of field care supervisors who are competent to work alongside care workers during their field shadowing training, so that they can appraise their performance in the field and decide if the new care worker is fit to”

Source location

Response from Lean on Me Care Agency
Page 4 · response
Published 13 March 2023

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.10

  1. 1

    Strengthen induction training on reporting unusable or outdated care plans.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
  2. 2

    Introduce new management and step down from the Registered Manager role.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
  3. 3

    Introduce electronic care-plan and assessment records and include their accuracy in spot checks.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
  4. 4

    Source leadership and management qualifications for management staff who lack them.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
  5. 5

    Maintain complete A-to-Z policies and procedures supplied by the consulting agency.

    Stated by Lean on Me Community Care Services LtdStated completedThe respondent said that this action was complete when they made their response on 13 March 2023.
  6. 6

    Provide mandatory refresher and continuing-professional-development training and implement ongoing performance monitoring.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
  7. 7

    Develop and implement new care-plan and risk-assessment formats.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
  8. 8

    Suspend trading and place the service into dormancy to re-evaluate operations, decision-making and organisational structure.

    Stated by Lean on Me Community Care Services LtdStated completedThe respondent said that this action was complete when they made their response on 13 March 2023.
  9. 9

    Provide office and senior staff training in written communication, blame-free culture, duty of candour, care planning and consent.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.
  10. 10

    Develop and implement quality-assurance and governance calendars and systems.

    Stated by Lean on Me Community Care Services LtdStated plannedThe respondent said that this action was planned when they made their response on 13 March 2023.

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

  1. 1

    Training cannot presently be funded for seven management staff because the provider requires between 12 and 12 attendees per course.

    Stated by Lean on Me Community Care Services LtdUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Strengthen induction training on reporting unusable or outdated care plans.

Verbatim wording from the response

“• Induction training to include the importance of reporting when care plans are not useful or out of date.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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

Introduce new management and step down from the Registered Manager role.

Verbatim wording from the response

“There will be new management in place. I will step down in my role as Registered Manager.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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

Introduce electronic care-plan and assessment records and include their accuracy in spot checks.

Verbatim wording from the response

“• Spot checks to include accuracy of the care plan and assessments, suitable recording format to be implemented. (Electronic recordings).”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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

Source leadership and management qualifications for management staff who lack them.

Verbatim wording from the response

“Lean on Me will also source out further training in Leadership and Management qualifications for those Management staff, who have not yet acquired such qualifications. This will be linked with the volume of clients we have acquired, that can enable us to sustain training support for of our staff, who are happy to acquire further skills in Health & Social Care.”

Source location

Response from Lean on Me Care Agency
Page 4 · response
Published 13 March 2023

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

Maintain complete A-to-Z policies and procedures supplied by the consulting agency.

Verbatim wording from the response

“(2). CQC EXPERTS has provided all new Policies and Procedures that are required to run an effective and efficient Health & Social Care Service. ████████ ████████. They have supplied over 600 new care documents to Lean On Me, including over 100 Policies and Procedures, available on request. Lean On Me now has complete A-Z Policies and Procedures in place.”

Source location

Response from Lean on Me Care Agency
Page 5 · response
Published 13 March 2023

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

Provide mandatory refresher and continuing-professional-development training and implement ongoing performance monitoring.

Verbatim wording from the response

“There will also be ongoing Refresher courses that are Mandatory for all Staff to attend as the need arises including Continuous Professional Development (CPD) courses. Ongoing performance monitoring will be implemented.”

Source location

Response from Lean on Me Care Agency
Page 4 · response
Published 13 March 2023

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 and implement new care-plan and risk-assessment formats.

Verbatim wording from the response

“• New care plan and risk assessment format to be developed and implemented.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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

Suspend trading and place the service into dormancy to re-evaluate operations, decision-making and organisational structure.

Verbatim wording from the response

“The seriousness of this accident prompted me to suspend trading and place LOM in dormancy to enable me to re-evaluate our entire operation, develop decision making and organisational structure with a service development blueprint for future practice.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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

Provide office and senior staff training in written communication, blame-free culture, duty of candour, care planning and consent.

Verbatim wording from the response

“• Office and senior staff training to include written communication skills.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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 and implement quality-assurance and governance calendars and systems.

Verbatim wording from the response

“• Quality assurance and governance - Calendar and systems to be developed and implemented.”

Source location

Response from Lean on Me Care Agency
Page 2 · response
Published 13 March 2023

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

Training cannot presently be funded for seven management staff because the provider requires between 12 and 12 attendees per course.

Verbatim wording from the response

“continue as a care worker or not. For those care workers who have not acquired RQF, they too will be supported to enrol in RQF courses.”

Source location

Response from Lean on Me Care Agency
Page 5 · response
Published 13 March 2023

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