PFD report

Jack Richard BROWN · Prevention of Future Deaths report

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Issued 18 Nov 2025•Northamptonshire

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
3

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 of care homes to ensure agency carers' suitability, experience and training
    Part of recurring concern: Inadequate competence assurance and induction for agency staffPart of recurring concern: Inadequate training and competence assurance for carers providing care
  2. Absence of a reporting route for concerns about care agencies
  3. Lack of regulatory inspection of care agency recruitment processes
    Part of recurring concern: Failure to provide effective regulatory oversight of providers serving vulnerable people
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

    Launch the Adult Social Care Learning and Development Support Scheme to fund eligible care staff courses and qualifications, including the Level 2 Adult Social Care Certificate.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 1 December 2025.
  2. Action

    Launch the Quality Assured Care Learning Service to help individuals and employers identify trusted sector learning and development opportunities.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 1 December 2025.
  3. Action

    Revise and expand the Care Workforce Pathway to provide a national structure for adult social care knowledge, skills, values, behaviours and progression.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 1 December 2025.

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

  1. Position

    Existing CQC registration requirements, staffing duties, training, supervision and regulatory action provide safeguards for agency staff suitability and competence.

    Stated by Department of Health and Social CareExisting 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 of care homes to ensure agency carers' suitability, experience and training

Wider context from the report

“At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur. ”

Is this part of a recurring concern?

Yes — Inadequate competence assurance and induction for agency staff; 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

Absence of a reporting route for concerns about care agencies

Wider context from the report

“At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur. ”

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

Lack of regulatory inspection of care agency recruitment processes

Wider context from the report

“At the inquest the court heard evidence that care agencies who provide agency care staff to care / nursing homes do not need to register with the CQC and are not regulated by any other body. The activities of such agencies are therefore not inspected or checked to ensure that they have rigorous recruitment processes and there is no one to report matters to when a concern is identified. This gives rise to a concern as care homes may rely on agencies to vet agency carers and have minimal input into suitability and training for the role. This creates a risk that agency care staff, who may be wholly unsuitable for the role, are providing care to vulnerable people without basic checks as to experience and suitability. This places service users at risk of harm and gives rise to a risk that future deaths could occur. ”

Is this part of a recurring concern?

Yes — Failure to provide effective regulatory oversight of providers serving vulnerable people.

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

Launch the Adult Social Care Learning and Development Support Scheme to fund eligible care staff courses and qualifications, including the Level 2 Adult Social Care Certificate.

Verbatim wording from the response

“The department also launched the Adult Social Care Learning and Development Support Scheme in September 2024, backed by up to £12 million this financial year for eligible care staff to undertake courses and qualifications, including the new Level 2 Adult Social Care Certificate. Developed from the Care Certificate standards, the Level 2 Adult Social Care”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 1 December 2025

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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

Launch the Quality Assured Care Learning Service to help individuals and employers identify trusted sector learning and development opportunities.

Verbatim wording from the response

“Certificate has been designed to support people in care roles to have the most up to date knowledge and baseline skills required to support people to succeed in their roles. To ensure training undertaken is of good quality, we also launched the Quality Assured Care Learning Service which supports individuals and employers to easily identify trusted learning and development opportunities which meet the needs of the sector.”

Source location

Response from Department for Health and Social Care
Page 3 · response
Published 1 December 2025

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

Revise and expand the Care Workforce Pathway to provide a national structure for adult social care knowledge, skills, values, behaviours and progression.

Verbatim wording from the response

“Further to those regulatory safeguards, the department is committed to enhancing the skills of staff working in adult social care, including those employed by agencies. It is vital to ensure that the care provided is of good quality, fair, personalised, and accessible. The department is supporting the professionalisation of the workforce through a range of activities which agencies can access for their employees. We recently revised and expanded the Care Workforce Pathway, the first national career structure for adult social care. This sets out the knowledge, skills, values, and behaviours needed to work in the sector and provides a framework for progression and development.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 1 December 2025

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

Existing CQC registration requirements, staffing duties, training, supervision and regulatory action provide safeguards for agency staff suitability and competence.

Verbatim wording from the response

“Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 1 December 2025

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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

Regulated care providers, rather than employment agencies, are responsible for ensuring agency staff are suitably experienced, competent and recruited safely.

Verbatim wording from the response

“Care homes and nursing homes do typically carry out regulated activity and therefore are registered with CQC. CQC requires all health and social care providers registered with them to deploy enough suitably qualified, competent and experienced staff (including both registered and unregistered professionals) to enable them to meet all other regulatory requirements described in Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These regulations apply to providers who recruit care staff via employment agencies. It is the responsibility of the regulated provider to ensure robust and safe recruitment practices are in place, and to make sure that all staff, including agency staff, are suitably experienced, competent and able to carry out their role.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 1 December 2025

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