Report evidence summary
Concerns raised 8 Failure to understand and follow the prescribed failed visits procedure View source Dissemination of inaccurate information about client welfare View source Failure of failed visits policies to give sufficient prominence to police involvement Part of recurring concern: Failure to escalate welfare concerns after unsuccessful contact View source Absence of a clear system for assessing and deciding referral priority View source Failure to clearly record keyholder identity and contact details View source Failure of the provider’s failed visits procedure to reflect the prescribed procedure View source Failure to adequately record carer calls about failed visits View source Failure to record referral priority decision-making View source See 5 more concerns
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 21
Careworld London Limited Update keyholder details for all service users and implement scheduling software to maintain accurate, accessible records.
View source
Careworld London Limited Implement a new Action Plan addressing failed visits and safeguarding concerns.
View source
Careworld London Limited Retrain all office staff and care workers on the revised Failed Visits policy and adult safeguarding principles.
View source
Careworld London Limited Update the Failed Visits policy to align with relevant local-authority procedures and strengthen escalation, communication recording and police involvement.
View source
Careworld London Limited Exchange policy information with Hackney to ensure procedures and practices operate together effectively.
View source
London Borough of Tower Hamlets Add accessible emergency-contact, key-holder, mobility and related front-sheet information requirements to the Failed Visits Procedure.
View source
London Borough of Tower Hamlets Run a referral-processing practice session addressing lessons from the case and implementation of the new procedure.
View source
London Borough of Tower Hamlets Formally launch the revised Failed Visits Procedure to Adult Social Care staff and commissioned providers.
View source
London Borough of Tower Hamlets Provide a dedicated First Response Officer and updated referral-processing procedures for prioritising and escalating out-of-hours and failed-visit reports.
View source
London Borough of Tower Hamlets Conduct an independent learning review after the section 42 enquiry and report its findings and recommendations to the Safeguarding Adults Board.
View source
London Borough of Tower Hamlets Report the case to the Safeguarding Adults Board subgroup.
View source
London Borough of Tower Hamlets Confirm that all commissioned providers hold the current Failed Visits Procedure.
View source
London Borough of Tower Hamlets Introduce a prominent emergency police-call checklist and clarify that any officer may call police when serious harm is suspected.
View source
London Borough of Tower Hamlets Ensure care providers are conversant with the Failed Visits Procedure.
View source
London Borough of Tower Hamlets Terminate the Careworld contract and transfer its Tower Hamlets care services to other commissioned providers.
View source
London Borough of Tower Hamlets Review the feedback loop between the Commissioning quality-monitoring team and Adult Social Care teams.
View source
London Borough of Tower Hamlets Remind care agencies of the Out of Hours Emergency Duty Service contact details.
View source
London Borough of Tower Hamlets Pilot a new carers’ assessment and raise the profile of carers in the borough.
View source
London Borough of Tower Hamlets Develop a single point of access for health and social care, including review of out-of-hours access and accessible case recording.
View source
London Borough of Tower Hamlets Keep vulnerable service users needing continual support allocated to a worker until a clear support plan is identified.
View source
London Borough of Tower Hamlets Revise the Failed Visits Procedure following consultation with provider services.
View source
× 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 understand and follow the prescribed failed visits procedure
Wider context from the report “(1) Tower Hamlet’s Failed Visits Procedure was poorly understood and not followed by Careworld staff , in particular (though not limited to): (a) the appropriate means of alerting Tower Hamlets to failed care visits that occurred during a weekend ; and (b) use of the Tower Hamlet’s pro forma Failed Visit Record ;
” 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 Dissemination of inaccurate information about client welfare
Wider context from the report “(4) No adequate record of calls from a carer to the Careworld Care Co-ordinator regarding failed visits was made, leading, in turn, to inaccurate information regarding the client’s welfare being disseminated to Tower Hamlets by another member of Careworld staff ;
” 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 Failure of failed visits policies to give sufficient prominence to police involvement
Wider context from the report “(5) Neither Tower Hamlets or Careworld’s Failed Visits policy gives any / any sufficient prominence to the possibility of involving the police if other attempts to confirm the individual’s welfare following a failed visit have proved unsuccessful;
” 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 clear system for assessing and deciding referral priority
Wider context from the report “(6) The absence of a clear / clearly understood system for the Adult Social Care Team to use on a Monday morning for assessing and deciding the priority of referrals from the Out of hours service made over the weekend (and for recording this decision-making).
” 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 Failure to clearly record keyholder identity and contact details
Wider context from the report “(3) Vital information regarding the identity of and contact details for the only other keyholder to the premises in this instance was not clearly recorded by either Tower Hamlets or Careworld;
” 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 Failure of the provider’s failed visits procedure to reflect the prescribed procedure
Wider context from the report “(2) Careworld’s own Failed Visits Procedure does not mirror or reflect aspects of Tower Hamlet’s prescribed procedure ;
” 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 Failure to adequately record carer calls about failed visits
Wider context from the report “(4) No adequate record of calls from a carer to the Careworld Care Co-ordinator regarding failed visits was made , leading, in turn, to inaccurate information regarding the client’s welfare being disseminated to Tower Hamlets by another member of Careworld staff;
” 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 Failure to record referral priority decision-making
Wider context from the report “(6) The absence of a clear / clearly understood system for the Adult Social Care Team to use on a Monday morning for assessing and deciding the priority of referrals from the Out of hours service made over the weekend (and for recording this decision-making) .
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report
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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 Update keyholder details for all service users and implement scheduling software to maintain accurate, accessible records.
Verbatim wording from the response “been addressed. It will be seen from the Action Plan that such details in respect of all 664 service users have now been updated. Dedicated scheduling software has now been put in place to ensure that such information is accurately recorded, up-to-date and accessible to all those who have need of it. Without wishing to descend into too great particularity, we append to this letter as Appendix E screenshots from the software used, that we hope give an indication of the way in which such records are now maintained;” Source location 2018-0200-Response-by-Careworld-London-Ltd
Open published response
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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 Implement a new Action Plan addressing failed visits and safeguarding concerns.
Verbatim wording from the response “(i) Careworld London has designed and implemented a new Action Plan, a copy of which is appended to this letter as Appendix A.” Source location 2018-0200-Response-by-Careworld-London-Ltd
Open published response
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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 Retrain all office staff and care workers on the revised Failed Visits policy and adult safeguarding principles.
Verbatim wording from the response “(ii) The Failed Visits policy itself has been updated - a copy is at Appendix B - and all Careworld London staff (both office staff and care workers) have been re-trained in respect of the content of the revised policy and in respect of the fundamental principles involved in safeguarding adults. All such training was completed by 3 August 2018.” Source location 2018-0200-Response-by-Careworld-London-Ltd
Open published response
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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 Update the Failed Visits policy to align with relevant local-authority procedures and strengthen escalation, communication recording and police involvement.
Verbatim wording from the response “(ii) The Failed Visits policy itself has been updated - a copy is at Appendix B - and all Careworld London staff (both office staff and care workers) have been re-trained in respect of the content of the revised policy and in respect of the fundamental principles involved in safeguarding adults. All such training was completed by 3 August 2018.” Source location 2018-0200-Response-by-Careworld-London-Ltd
Open published response
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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 Exchange policy information with Hackney to ensure procedures and practices operate together effectively.
Verbatim wording from the response “(v) The revisions to the Careworld London “Failed Visits” policy and procedures are specifically designed to ensure that they do now “mirror and /or reflect” the policies and procedures followed by the relevant local authorities with whom we work (See Matter of Concern 2 – above). It is recognised that a disjoint between differently designed policies operated by different agencies had created potential for difficulties in the past. Careworld London no longer works with Tower Hamlets but does provide services to the Hackney Children, Adults and Community Health Department. There has been liaison between Careworld London and Hackney and we attach by way of evidence (at Appendix D) a letter dated 9 August 2018, demonstrating the manner in which information on policy is now exchanged with a view to ensuring that procedures and practices operate together effectively.” Source location 2018-0200-Response-by-Careworld-London-Ltd
Open published response
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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 Add accessible emergency-contact, key-holder, mobility and related front-sheet information requirements to the Failed Visits Procedure.
Verbatim wording from the response “18. The revised policy addresses the above recommendation. It now includes a section on “being prepared” which highlights the importance of good record-keeping. This section in the procedure aims to ensure that services that may encounter a “failed visit” situation are equipped with the right information to enable them to act quickly and effectively. This includes, for example, the requirement to hold essential information such as the names, addresses and telephone numbers of emergency contacts, family and friends, the nearest key holder, any mobility issues and whether the person is known to leave their property or not. The procedure requires that this information be accessible to those who may need it, any time, day or night.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Run a referral-processing practice session addressing lessons from the case and implementation of the new procedure.
Verbatim wording from the response “23. The Referral Processing section in the Assessment & Intervention Team ran a practice session on 2 August 2018 where they looked at the lessons learned from Mr Lugg’s case and implementing the new procedure for their section.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Formally launch the revised Failed Visits Procedure to Adult Social Care staff and commissioned providers.
Verbatim wording from the response “17. The Council’s Failed Visits Procedure has been reviewed and following consultation, including with our provider services, it is being revised. The revised policy will be signed off and formally launched with the Adult Social Care and commissioned providers in August 2018.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 a dedicated First Response Officer and updated referral-processing procedures for prioritising and escalating out-of-hours and failed-visit reports.
Verbatim wording from the response “22. The Assessment & Intervention Team (Adult Social Care) has reviewed its service delivery model and now has additional resources to cover the referral processing section. A First Response Officer is dedicated to managing the email referrals between the hours of 9am – 5pm, every day. This enables any urgent referrals to be picked up immediately. The officer prioritises the Emergency Duty Team (Out of Hours) reports and other failed visit reports each morning, including after a weekend. Any such” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Conduct an independent learning review after the section 42 enquiry and report its findings and recommendations to the Safeguarding Adults Board.
Verbatim wording from the response “27. We have reported this case to the Safeguarding Adults Board (‘SAB’) subgroup. There will be an independent learning review as a follow up to the section 42 enquiry which will take into consideration other cases where there are similar themes in learning. Whilst more immediate actions have been taken in relation to the learning in this case, the full findings and recommendations of the independent review will be reported to the Safeguarding Adults Board and any further recommendations followed up.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Report the case to the Safeguarding Adults Board subgroup.
Verbatim wording from the response “27. We have reported this case to the Safeguarding Adults Board (‘SAB’) subgroup. There will be an independent learning review as a follow up to the section 42 enquiry which will take into consideration other cases where there are similar themes in learning. Whilst more immediate actions have been taken in relation to the learning in this case, the full findings and recommendations of the independent review will be reported to the Safeguarding Adults Board and any further recommendations followed up.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Confirm that all commissioned providers hold the current Failed Visits Procedure.
Verbatim wording from the response “9. Since the inquest the Council has confirmed with all providers that they have a copy of the current Failed Visits Procedure and those providers have also been consulted on the proposed revisions to the Procedure referenced elsewhere in this response.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Introduce a prominent emergency police-call checklist and clarify that any officer may call police when serious harm is suspected.
Verbatim wording from the response “20. The Council’s revised Failed Visits Procedure now includes a one-page checklist which makes more prominent the requirement to call the Police in an emergency situation, following some quick checks to locate the person:-” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Ensure care providers are conversant with the Failed Visits Procedure.
Verbatim wording from the response “v) The care providers are required to follow a Failed Visit Procedure which requires them to check with various agencies such as the hospital, police, and next of kin while also alerting the local authority. As this does not appear to have been fully implemented in this case, the local authority now ensures care providers are conversant with the Failed Visit Procedure.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Terminate the Careworld contract and transfer its Tower Hamlets care services to other commissioned providers.
Verbatim wording from the response “11. Based on the findings from this contract review process the Council has determined to terminate our contract with Careworld and the termination notice has now been served. All care services provided by Careworld in Tower Hamlets are therefore being transferred to other commissioned providers on 20 August 2018.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Review the feedback loop between the Commissioning quality-monitoring team and Adult Social Care teams.
Verbatim wording from the response “• A review of the feedback loop between the quality monitoring team in Commissioning and Adult Social Care teams.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Remind care agencies of the Out of Hours Emergency Duty Service contact details.
Verbatim wording from the response “Brokerage Team now reminds care agencies of the contact details for our Out of Hours Emergency Duty Service.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Pilot a new carers’ assessment and raise the profile of carers in the borough.
Verbatim wording from the response “• Piloting a new carers’ assessment and raising the profile of carers in the borough” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Develop a single point of access for health and social care, including review of out-of-hours access and accessible case recording.
Verbatim wording from the response “• Developing a single point of access for health and social care which includes a review of the Out of Hours service. This will cover how the service is accessed as well as case recording which is accessible to those who need to see it.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Keep vulnerable service users needing continual support allocated to a worker until a clear support plan is identified.
Verbatim wording from the response “ii) The gap between November 2017 and February 2018 during which there was no allocated social worker to Mr Lugg. In hindsight, this should have been considered more carefully. Whilst I note that there were no incidents or concerns raised regarding Mr Lugg’s care over that time, consideration should be given to Mr Lugg’s history of non-engagement and the need for continual support and monitoring. In future, service users who are vulnerable and need continual support will remain allocated to a worker until a clear plan of support is identified.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 Revise the Failed Visits Procedure following consultation with provider services.
Verbatim wording from the response “17. The Council’s Failed Visits Procedure has been reviewed and following consultation, including with our provider services, it is being revised. The revised policy will be signed off and formally launched with the Adult Social Care and commissioned providers in August 2018.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
Open published response
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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 failed visits procedure and staff competency requirements were clearly specified in commissioned home-care contracts.
Verbatim wording from the response “8. It is the Council’s view, that the requirement both to comply with the Council’s Failed Visits Procedure and to ensure that care staff are competent in complying with the said procedure is clearly specified.” Source location 2018-0200-Response-by-London-Borough-of-Tower-Hamlets
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