PFD report

Maureen Ann Colclough · Prevention of Future Deaths report

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Issued 27 Jul 2017•Cheshire

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
2

Raised in this report

Recipients
4

Named on the report

Responses found
2

Of 4 recipients

Stated actions
11

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. Inadequate staff training to recognise emergency situations
    Part of recurring concern: Inadequate staff training for emergency response
  2. Reliance on presumptions when assessing unresponsive patients in serious situations
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.6

  1. Action

    Complete an inspection reviewing emergency training and service oversight.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
  2. Action

    Notify all employees about emergency recognition and response requirements.

    Stated by Unique Care ServicesStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
  3. Action

    Notify employees that attendance at an additional Emergency First Aid course is mandatory.

    Stated by Unique Care ServicesStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The claim that relevant first-aid training was not provided is disputed; training records and qualification certificates were supplied as evidence.

    Stated by Unique Care ServicesDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 staff training to recognise emergency situations

Wider context from the report

“1. Inadequate training of staff to recognise emergency situation. ”

Is this part of a recurring concern?

Yes — Inadequate staff training for emergency response.

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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

Reliance on presumptions when assessing unresponsive patients in serious situations

Wider context from the report

“2. Relying on presumptions when finding an unresponsive patient in a serious situation. ”

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

Complete an inspection reviewing emergency training and service oversight.

Verbatim wording from the response

“We also agreed to conduct an inspection of the service, reviewing staff training in the event of an emergency and also the oversight that is provided by ████████. Two inspectors visited the service on 11 September 2017 and 21 September. I have detailed some of our findings under your specific questions below.”

Source location

2017-0318-Response-by-CQC
Page 2 · response
Published 3 December 2017

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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

Notify all employees about emergency recognition and response requirements.

Verbatim wording from the response

“• All employees have been notified and almost ALL have undertaken a revised performance appraisal (regardless of any recent or up to date training) containing specific information and questions relating to recognizing an emergency situation as well as steps to take when finding an unresponsive service user.”

Source location

2017-0318-Response-by-Unique-Care-Services
Page 1 · response
Published 3 December 2017

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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

Notify employees that attendance at an additional Emergency First Aid course is mandatory.

Verbatim wording from the response

“• All employees of Unique Care Services have been made aware of that they MUST attend an extra Emergency First Aid training course on either of the dates provided and confirmed (Tuesday 26th September & Tuesday 3rd October)”

Source location

2017-0318-Response-by-Unique-Care-Services
Page 1 · response
Published 3 December 2017

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

Complete revised performance appraisals covering emergency recognition and response for remaining employees.

Verbatim wording from the response

“• All employees have been notified and almost ALL have undertaken a revised performance appraisal (regardless of any recent or up to date training) containing specific information and questions relating to recognizing an emergency situation as well as steps to take when finding an unresponsive service user.”

Source location

2017-0318-Response-by-Unique-Care-Services
Page 1 · response
Published 3 December 2017

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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

Deliver the additional mandatory Emergency First Aid course on one of the confirmed dates.

Verbatim wording from the response

“• All employees of Unique Care Services have been made aware of that they MUST attend an extra Emergency First Aid training course on either of the dates provided and confirmed (Tuesday 26th September & Tuesday 3rd October)”

Source location

2017-0318-Response-by-Unique-Care-Services
Page 1 · response
Published 3 December 2017

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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 new starters with emergency-response information and assess their competence through questions and demonstration.

Verbatim wording from the response

“• All new starters will be given the relevant information and must answer a series of questions and show a satisfactory level of competence and understanding in recognizing an emergency situation and responding accordingly. (Employees have always been given this information in the past in the form of a handbook and have been required to sign to confirm receipt)”

Source location

2017-0318-Response-by-Unique-Care-Services
Page 1 · response
Published 3 December 2017

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

The claim that relevant first-aid training was not provided is disputed; training records and qualification certificates were supplied as evidence.

Verbatim wording from the response

“Please allow me to state that we as a company have ALWAYS provided the relevant training as well as promoting the options of many other training courses and qualifications even for developing skills unrelated to Domiciliary Care.”

Source location

2017-0318-Response-by-Unique-Care-Services
Page 2 · response
Published 3 December 2017

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.5

  1. 1

    Continue monitoring the service to ensure safe and effective care.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 3 December 2017.
  2. 2

    Take substantive enforcement action in response to inspection concerns.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 3 December 2017.
  3. 3

    Consider whether criminal enforcement action is appropriate against the Registered Provider.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 3 December 2017.
  4. 4

    Require the Registered Provider to submit an action plan explaining how care will be improved.

    Stated by Care Quality CommissionStatus unclearThe respondent did not make the status of this action clear when they made their response on 3 December 2017.
  5. 5

    Publish the inspection findings report on the website.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 3 December 2017.

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 monitoring the service to ensure safe and effective care.

Verbatim wording from the response

“Due to the concerns found during our inspection CQC is now taking substantive enforcement action. In addition, the Registered Provider is required to provide CQC with an action plan detailing how they intend to improve the care provided to service users. Inspectors will continue to monitor the service to ensure that service users receive safe and effective care.”

Source location

2017-0318-Response-by-CQC
Page 3 · response
Published 3 December 2017

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

Take substantive enforcement action in response to inspection concerns.

Verbatim wording from the response

“Due to the concerns found during our inspection CQC is now taking substantive enforcement action. In addition, the Registered Provider is required to provide CQC with an action plan detailing how they intend to improve the care provided to service users. Inspectors will continue to monitor the service to ensure that service users receive safe and effective care.”

Source location

2017-0318-Response-by-CQC
Page 3 · response
Published 3 December 2017

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 whether criminal enforcement action is appropriate against the Registered Provider.

Verbatim wording from the response

“Following the receipt of the Regulation 28 Report we held three internal management review meetings to discuss the findings of the report and determine what action CQC should take. We reviewed our records and found that the Registered Provider had not notified us of the death of Maureen Ann Colclough as legally required. This failure to report has been raised with the Registered Provider and we will consider whether criminal enforcement action is appropriate.”

Source location

2017-0318-Response-by-CQC
Page 1 · response
Published 3 December 2017

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 the Registered Provider to submit an action plan explaining how care will be improved.

Verbatim wording from the response

“Due to the concerns found during our inspection CQC is now taking substantive enforcement action. In addition, the Registered Provider is required to provide CQC with an action plan detailing how they intend to improve the care provided to service users. Inspectors will continue to monitor the service to ensure that service users receive safe and effective care.”

Source location

2017-0318-Response-by-CQC
Page 3 · response
Published 3 December 2017

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

Publish the inspection findings report on the website.

Verbatim wording from the response

“A copy of the report detailing our findings will be available when published on our website.”

Source location

2017-0318-Response-by-CQC
Page 3 · response
Published 3 December 2017

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