PFD report

Ivy Atkin · Prevention of Future Deaths report

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Issued 25 Oct 2016•Nottinghamshire

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
3

Named on the report

Responses found
2

Of 3 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. Lack of reliable independent and objective assessment of Nominated Individual suitability
  2. Failure to obtain and consider DBS certificates for proposed Nominated Individuals
    Part of recurring concern: Unreliable criminal-conviction vetting for safety-sensitive roles
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

    Continue reviewing whether to formalise independent checks for cases where a director and nominated individual are the same person.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2016.
  2. Action

    Develop a registration-application triage system to route higher-risk applications through appropriate processes and streamline lower-risk applications.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2016.
  3. Action

    Evaluate how CQC applies the fit-and-proper-person test, including risks arising within smaller providers.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    CQC will not directly check nominated individuals’ DBS records because it lacks power to approve or refuse their appointment as nominated individuals.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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 reliable independent and objective assessment of Nominated Individual suitability

Wider context from the report

“1. ████████ had criminal convictions including for an offence involving violence against another person. He had not provided a Disclosure and Barring Service (“DBS”) certificate to the CQC nor been asked to do so, before becoming Nominated Individual. 2. The CQC were therefore unable to assess whether or not ████████ was of good character and was suitable for the position of Nominated Individual, that person being responsible for the supervising the management of a Residential Care Home, a role which ████████ undertook. 3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual, where the Provider is (as was here) a limited company. 4. In the case of a small family owned limited company, where the controlling director and Nominated Individual are one and the same person, as in this case, there is therefore no reliable nor independent nor objective means of assessing the good character, safety and suitability of a Nominated Individual. 5. This is because the wording of the present Regulation 6 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 allows for such a “loophole”, and/or in the alternative the manner in which the CQC interprets its powers and duties in the light of this Regulation allows for such a loophole. ”

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 obtain and consider DBS certificates for proposed Nominated Individuals

Wider context from the report

“1. ████████ had criminal convictions including for an offence involving violence against another person. He had not provided a Disclosure and Barring Service (“DBS”) certificate to the CQC nor been asked to do so, before becoming Nominated Individual. 2. The CQC were therefore unable to assess whether or not ████████ was of good character and was suitable for the position of Nominated Individual, that person being responsible for the supervising the management of a Residential Care Home, a role which ████████ undertook. 3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual, where the Provider is (as was here) a limited company. 4. In the case of a small family owned limited company, where the controlling director and Nominated Individual are one and the same person, as in this case, there is therefore no reliable nor independent nor objective means of assessing the good character, safety and suitability of a Nominated Individual. 5. This is because the wording of the present Regulation 6 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 allows for such a “loophole”, and/or in the alternative the manner in which the CQC interprets its powers and duties in the light of this Regulation allows for such a loophole. ”

Is this part of a recurring concern?

Yes — Unreliable criminal-conviction vetting for safety-sensitive roles.

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

Continue reviewing whether to formalise independent checks for cases where a director and nominated individual are the same person.

Verbatim wording from the response

“Furthermore, we would require greater assurance where the director and nominated individual is the same person, a situation which is more common amongst small providers. As part of continuing review of the position one option in the future may be to formalise independent checks but work is ongoing to consider how this would operate in practice and where the responsibility would lie in performing such checks.”

Source location

2016-0379-Response-by-Care-Quality-Commission
Page 3 · response
Published 25 October 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

Develop a registration-application triage system to route higher-risk applications through appropriate processes and streamline lower-risk applications.

Verbatim wording from the response

“An issue does however remain that FPPR may potentially be less effective in small providers due to the risk of overlap between directors and nominated individuals or other senior managers and the potential lack of assurance this would provide that proper checks were being carried out. Work is currently underway to evaluate how CQC use the fit and proper person test and it has been identified as part of this work that there continues to be risks within smaller providers. In practice our registration teams may address this risk. Work is underway to develop a triage system for registration applications to ensure that higher risk applications go through an appropriate process, and to streamline our processes for those that are lower risk.”

Source location

2016-0379-Response-by-Care-Quality-Commission
Page 3 · response
Published 25 October 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

Evaluate how CQC applies the fit-and-proper-person test, including risks arising within smaller providers.

Verbatim wording from the response

“An issue does however remain that FPPR may potentially be less effective in small providers due to the risk of overlap between directors and nominated individuals or other senior managers and the potential lack of assurance this would provide that proper checks were being carried out. Work is currently underway to evaluate how CQC use the fit and proper person test and it has been identified as part of this work that there continues to be risks within smaller providers. In practice our registration teams may address this risk. Work is underway to develop a triage system for registration applications to ensure that higher risk applications go through an appropriate process, and to streamline our processes for those that are lower risk.”

Source location

2016-0379-Response-by-Care-Quality-Commission
Page 3 · response
Published 25 October 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

CQC will not directly check nominated individuals’ DBS records because it lacks power to approve or refuse their appointment as nominated individuals.

Verbatim wording from the response

“Having given very careful consideration to the concerns you have raised we have concluded that CQC should not directly check the DBS for Nominated Individuals. This decision was authorised by ████████, Chief Inspector, Adult Social Care.”

Source location

2016-0379-Response-by-Care-Quality-Commission
Page 2 · response
Published 25 October 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

Providers are responsible for assessing nominated individuals’ suitability and conducting appropriate enquiries, including DBS checks where necessary.

Verbatim wording from the response

“3. This is because the CQC expected and still expects a Provider to consider DBS certificates and make decisions as to the suitability of a proposed Nominated Individual, where the Provider is (as was here) a limited company.”

Source location

2016-0379-Response-by-Care-Quality-Commission
Page 1 · response
Published 25 October 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

Providers remain responsible for managing and delivering care; CQC should not oversee providers’ management decisions.

Verbatim wording from the response

“The underpinning principle of the regulatory regime in health and social care is that providers remain responsible for the management and delivery of the care that they offer. The role of the CQC is to assess providers to give assurance that they are taking the necessary steps to fulfil their legal duties and, where appropriate, to take regulatory enforcement action if providers are failing in their duty. In the view of the Department of Health, it would be neither desirable nor practical for the CQC to take on a role in which it was overseeing the management decisions of providers. For this reason, the legislation is established in a way that requires providers to demonstrate to the CQC that they have appropriate systems and processes in place to manage and oversee the care that they provide.”

Source location

2016-0379-Response-by-Department-of-Health
Page 2 · response
Published 25 October 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

Existing Fit and Proper Persons Requirements provide CQC with sufficient powers to oversee providers’ appointment of directors.

Verbatim wording from the response

“CQC’s response to your letter also details changes to the legislation that have come into place since 2012 relating to the Fit and Proper Persons Requirements (Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). These regulations require that a provider must check that an individual is of good character, with the necessary skills and qualifications and has not been involved in previous misconduct or mismanagement before they can be appointed as a director of a provider. This regulation places wide duties of diligence on providers, and the CQC’s role will be to ensure that providers have proper systems and processes in place to undertake these assessments. If the CQC has concerns about the process of decisions that a provider is taking when appointing directors, it can use its regulatory powers.”

Source location

2016-0379-Response-by-Department-of-Health
Page 2 · response
Published 25 October 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

The existing nominated-individual arrangements and CQC’s general powers provide proportionate assurance, so the system should be maintained.

Verbatim wording from the response

“You raise concerns around the role of the nominated individual, particularly the fact that CQC does not check DBS records for individuals fulfilling this role. The role of the nominated individual is essentially that of a point of contact between the care provider and the CQC for the purposes of correspondence and other regulatory business. For this reason, the nominated individual is not registered directly with the CQC. This is different in the case of Registered Managers, who are legally responsible for the care being delivered within care organisations; these individuals are registered directly with the CQC, and therefore vetted more closely by CQC upon registration.”

Source location

2016-0379-Response-by-Department-of-Health
Page 2 · response
Published 25 October 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

    Explore provider-organisation size as a potential risk factor when assessing registration applications.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2016.
  2. 2

    Engage Department of Health colleagues on the concerns about nominated-individual suitability and oversight.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 25 October 2016.
  3. 3

    Establish a cross-team working group to examine the concerns about nominated-individual suitability and oversight.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 25 October 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

Explore provider-organisation size as a potential risk factor when assessing registration applications.

Verbatim wording from the response

“The size of provider organisations is being explored as a potential risk factor within this work, to ensure that such applications continue to be given appropriate consideration. It is anticipated that changes will be made with regard to these areas during 2018.”

Source location

2016-0379-Response-by-Care-Quality-Commission
Page 3 · response
Published 25 October 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

Engage Department of Health colleagues on the concerns about nominated-individual suitability and oversight.

Verbatim wording from the response

“Given the seriousness of your concerns and the implications it could present a working group was set up comprising of CQC staff from various teams including representatives from operational inspection and registration teams, Government engagement team, legal team, policy team and our strategy team. We also liaised with colleagues in the Department of Health.”

Source location

2016-0379-Response-by-Care-Quality-Commission
Page 2 · response
Published 25 October 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

Establish a cross-team working group to examine the concerns about nominated-individual suitability and oversight.

Verbatim wording from the response

“Given the seriousness of your concerns and the implications it could present a working group was set up comprising of CQC staff from various teams including representatives from operational inspection and registration teams, Government engagement team, legal team, policy team and our strategy team. We also liaised with colleagues in the Department of Health.”

Source location

2016-0379-Response-by-Care-Quality-Commission
Page 2 · response
Published 25 October 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