Michael Waite

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

www.cqc.org.uk 

HM Coroner Mr. Horstead 
HM Coroner’s Officer Essex Coroner’s Service 
Ground Floor 
Seax House 
Essex County Council 
Victoria Road South 
Chelmsford 
CM1 1LX 

26 March 2024  

Care Quality Commission 

Dear HM Coroner Sean Horstead 

CQC response to prevention of future death report Michael Brian Waite 

Thank  you  for  naming  the  Care  Quality  Commission  (CQC)  as  a  respondent  in  the 
prevention of future death report issued following the death of Michael Brian Waite on 19 
August 2022.  

The CQC is the independent regulator of health and social care in England. We gather 
and analyse data from people who use services, providers, and our system partners 
and stakeholders to help us to monitor the quality of care and to be more targeted with 
what we look at during our inspections. This forms the basis of our intelligence-driven 
approach to inspection. We take enforcement action if providers are not meeting the 
regulations.  We  encourage  all  services  to  improve,  whatever  their  level  of 
performance. 

The relevant regulation concerning this matter is the Health and Social Care Act 2008 
(Regulated Activities) Regulations 2014; Regulation 18: staffing. 

The intention of this regulation is to make sure that providers deploy enough suitably 
qualified,  competent and experienced staff to enable them to meet all other regulatory 
requirements described in this part of the Health and Social Care Act 2008 (Regulated 
Activities) Regulations 2014. To meet the regulation, providers must provide sufficient 
numbers  of  suitably  qualified,  competent,  skilled  and  experienced  staff  to meet  the 
needs  of  the  people  using  the  service  at  all  times  and  the  other  regulatory 
requirements  set  out  in  this  part  of  the  above  regulations.  Staff  must  receive  the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 support,  training,  professional  development,  supervision  and  appraisals  that  are 
necessary  for  them  to  carry  out  their  role  and  responsibilities.  They  should  be 
supported to obtain further qualifications and provide evidence, where required, to the 
appropriate  regulator  to  show that  they  meet  the  professional  standards  needed to 
continue to practise. 

Following receipt of  your  prevention of future deaths report,  the  CQC commenced  a 
responsive assessment to assess the service on training and learning culture;  and on 27 
February 2024, requested that the provider forward details on the actions taken since Mr. 
Waite’s death, including the investigation report and lessons learnt by the provider in 
their  effort  to  reduce  the  risk  of  a  similar  incident  occurring.  We  also  requested 
information on any additional actions the provider intended to take, in response to the 
prevention of future death report (including clear timescales).  

On 11 March 2024, the provider submitted copies of the accident and incident reporting 
form  and  investigation  review  report  produced  following  Mr.  Waite’s  death.  We  also 
received associated care plan and staff training documentation. On 19 March 2024, we 
met with the provider to discuss this submission and to identity any proposed additional 
actions in response to your prevention of future death report.  

The above took place to enable us to respond to the concerns raised in your Regulation 
28  prevention  of  future  deaths  report  and  to  make  an assessment  as  to  whether  we 
needed to take further action. We deal with each of your concerns as follows:  

1.  Although  the  support  worker  involved  in  this  case  had  received  Basic  Life 
Support training, the evidence of senior witnesses for Peabody, including the 
Assistant  Head  of  Service  and  the  Director  of  Care,  confirmed  that  there  is 
presently  no  requirement  for  Support  Workers,  employed  by  Peabody  to 
provide 24-hour solo support to clients in supported living accommodation, to 
undergo  certificated  First  Aid  Training  including  Basic  Life  Support  training, 
prior to assuming their role.  

The  provider  has  confirmed  that  their  protocols  have  now  been  revised;  such  that 
enhanced  emergency  first  aid  training  (incorporating  basic  life  support)  is  now  a 
mandatory part of training for all new support workers. The provider has also confirmed 
they  are  in  the  process  of  ensuring  that  all  existing  support  workers  complete  this 
enhanced training within 12 months.  

2.  Whilst it is recognised that residents in supported living accommodation have 
varying capabilities and varying abilities to care for themselves, as in this case, 
many will require help and support and, as such, will have varying - including 
significant  -  degrees  of  vulnerability.  In  my  view,  for  those  who  are  solo 
providers of support in such circumstances (i.e. are working alone in providing 
the support required) to not have received formal, certificated First Aid training, 
including Basic Life Support training, prior to assuming their duties gives rise to 
the risk of future deaths. 

The provider has confirmed that protocols have now been revised so that no support 
worker  across  the  organisation  is  allowed  to  lone  work  without  having  undertaken 
enhanced training (comprised of emergency first aid and basic life support training). 

 
 
 
 
 
 
 
 However, as highlighted above, we have been advised that the entire existing support 
worker workforce will not have completed their enhanced training for 12 months. This 
risk is partially mitigated by a new provider requirement that, where support workers 
are working together, one must have completed enhanced training.  
To  conclude,  Peabody  have  mitigated  the  risk  of  future  occurrence  by  ensuring 
enhanced emergency first aid training is available to all new and existing staff. Whilst 
existing staff are trained, Peabody are ensuring that there will be appropriately trained 
personnel on every shift.  

Since 1 April 2015 CQC has assumed enforcement responsibility for health and 
safety incidents where patients and service users have died or sustained avoidable 
harm or have been exposed to a significant risk of avoidable harm as a result of a 
failure by the registered person to provide safe care or treatment. As a result of the 
information you have shared in this case, CQC will be considering Mr Waite’s case 
under this framework.  

Yours Sincerely, 

Interim Operations Manager

25 March 2024 

Sean Horstead 
Area Coroner 
Essex Coroners Service 
Seax House 
Victoria Road South 
Chelmsford 
CM1 1QH 

Dear Mr Horstead, 

Re: Peabody response to the Prevention of Future Deaths report  

I am writing to update you on the actions we have taken following Mr Michael Waite’s death 
and the subsequent Prevention of Future Deaths report (Regulation 28). 

First, I would like to extend my condolences to Mr Waite’s family. Michael was a wonderful 
person who brought joy to all who knew him. He continues to be missed by our colleagues 
and residents.  

The concern that has been identified in the PFD report is that there is no requirement for 
care workers employed by Peabody to provide support to customers in a supported living 
environment to undergo certified First Aid and Basic Life Support training prior to starting 
work providing solo support to customers.  

In the sad case of Mr Waite, the care worker who assisted him when he was taken unwell 
had completed his Basic Life Support training. Moreover, the issue of a care worker who has 
not completed their basic life support and first aid training prior to them starting to work alone 
has not given rise to any incidents to date. 

However, we accept and understand the concerns highlighted by the Coroner during this 
inquest and are keen to ensure that all learning is captured and acted upon, in order to 
ensure that the service we provide to our customers remains of the highest standard. 

Therefore, we have now improved our training programme for care workers who assist 
customers in supported living environments. I have set out below all the steps we have taken 
to address the concerns raised in the report. 

Statutory requirements for basic life support and first aid training for care workers 

We have reviewed the statutory requirements in relation to the training and provision of 
suitably qualified staff to support customers in a supported living or domiciliary care 
environment. This would include customers such as Mr Waite, who received a domiciliary 
care service in his own home.  

Personal care is a regulated activity under The Health and Social Care Act 2008 (Regulated 
Activities) Regulations 2014. Section 18 of the Act states: 

18.—(1) Sufficient numbers of suitably qualified, competent, skilled and experienced persons 
must be deployed in order to meet the requirements of this Part. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (2) Persons employed by the service provider in the provision of a regulated activity 

(1) 
must— 

(a) receive such appropriate support, training, professional development, supervision and 
appraisal as is necessary to enable them to carry out the duties they are employed to 
perform, 

(b) be enabled where appropriate to obtain further qualifications appropriate to the work they 
perform… 

The Care Quality Commission (CQC) is responsible for ensuring registered providers adhere 
to The Act. In doing so, the CQC have developed a set of Fundamental Standards, which 
help define the points set out in The Act. Further to this an organisation called Skills For 
Care worked in collaboration with Skills For Health and Health Education England to set a 
minimum training standard for people working in the Adult Social Care sector. This minimum 
standard is currently defined in the Care Certificate.  

There is no statutory requirement to complete the Care Certificate and as such the CQC 
cannot enforce its use. However, CQC inspectors can enforce regulations covering how care 
colleagues are trained.  

The Care Certificate was designed to ensure those minimum standards are met and is 
generally considered an industry standard. Standard 12 in the Care Certificate covers Basic 
Life Support. Skills For Care state that “The minimum that should be covered is practical 
simulation of Cardio-Pulmonary Resuscitation (CPR).”  

All our new care workers working in a domiciliary care service complete this certificate. Even 
although their certificate can be brought across from a previous organisation, we still ask 
them to complete it again when they join us. This ensures we are confident in the quality of 
their training. We know many other providers take this approach as well. 

Actions taken by Peabody regarding basic life support and first aid training 

Our South Essex Domiciliary Care service was inspected by the CQC in July 2023, after Mr 
Waite’s sad death. The service retained its overall ‘Good’ rating. This rating was given to all 
five domains, including ‘Safe’, which incorporates colleague training and fitness to work. 
Training requirements were considered as part of the inspection and there were no notable 
concerns. 

This is partly because our existing training programme already meets the minimum 
standards for Basic Life Support training identified in the Care Certificate. 

However, upon careful consideration of the risks raised by the Coroner and having reviewed 
the risks inherent with our supported living customers, we have put in place additional 
measures to improve our training and quality of service. 

As a result, we have introduced a revised training programme for our care workers. This 
includes a more advanced, certified Emergency First Aid training course (which incorporates 
Basic Life Support). It is a one-day, in person course provided by Nuco Training Limited 
(details attached). In addition to using an external provider, we will also be delivering more 
training in-house. 

All our new care workers will complete the enhanced training programme as part of their 
induction process. They will be required to complete the Emergency First Aid training  

 
 
 
 
 
 
 component within their first month of starting with us during which time they will not be 
allowed to lone work. 

Our existing care workers will also be required to complete the new course. This affects over 
420 employees. We have given ourselves a target of one year to complete the roll out of this 
training programme, which has already commenced. This is on top of the basic life support 
training that our existing care workers who provide solo support have already completed. 

To ensure training is kept up to date, we use a learning management system called My 
Learning. This allows our colleagues to book training and complete e-learning from any 
device, at the time of their choosing. This includes refresher training which is set according 
to the course and the role of the worker. It also gives managers oversight of their teams’ 
learning activity. Our colleagues and their line managers receive automated reminders when 
a course is due for completion or renewal. 

We also receive monthly training compliance reports from our learning and development 
department and have a digital dashboard that shows compliance per team for each course. 

We recognise the need to continue upskilling our workforce into the future and maintain our 
resilience to changing customer needs. Therefore, we have also recently launched an 
Ofsted-registered Academy within our organisation, which will provide Care Certificate 
Training and also Level 3 Adult Care Worker standard and Level 4 Adult Care Practitioner 
standard apprenticeships.  

Thank you for highlighting your concerns in the PFD report and I hope you feel that our 
response to Michael’s tragic death has been robust and swift. 

If you would like any additional information, please do not hesitate to contact me.  

Yours sincerely 

CEO 

CC:   Care Quality Commission 

Skills For Care

11 March 2024 

Mr Sean Horstead 
HM Area Coroner for Essex 
Essex Coroner's Service 
Chelmsford County Hall 
Seax House, 
Victoria Rd South 
Chelmsford 
CM1 1QH 

Regulation 28: Report to Prevent Future Deaths: Michael Brian Waite 

Dear Mr Horstead, 

Thank you very much for sharing a copy of your report with Skills for Care and giving 
us the opportunity to respond.  

Firstly, we would like to express our deepest sympathies to the family, friends and 
carers of Mr Waite for their loss at what will continue to be a difficult time. 

Skills for Care is the strategic workforce development and planning body for adult 
social care in England. Whilst we have no regulatory remit, we strive to support the 
adult social care sector to consider good and best practice approaches to enable it to 
always deliver quality care. 

Our guidance and advice is informed by consultation with employers and includes 
recommendations related to workforce development. This advice spans the initial 
induction training for new care workers, through to the refreshing of knowledge and 
skills of experienced workers, as well as their longer-term development.  

Our advice includes encouraging adult social care providers to arrange training and 
assessment related to First Aid, including Basic Life Support for frontline carers from 
the moment they join the sector to the end of their careers. 

Our guidance and advice include: 

Core and Mandatory training 

This guidance is currently being updated in line with the Care Quality Commission’s 
new Single Assessment Framework and is due for republication in spring 2024.  

Pertinent to this request, our current guidance states that all care workers should 
‘Understand and know how to follow procedures for responding to accidents and 
sudden illness’ and ‘Be able to provide basic life support’.   

In line with HSE guidance, it further states that ‘Establishments must provide 
adequate personnel to respond if someone is taken ill or injured at work. It’s the 
employer’s responsibility to determine how many people need training and to what 
level.’   We note that this HSE guidance applies to First Aid and First Aid at Work, 
not specifically to Basic Life Support. 

 
 
 The adult social care sector’s statutory training requirements for the non-regulated 
workforce are drawn from general employer requirements, e.g. in relation health and 
safety, or from CQC regulations.   

CQC recommendations 

We note that the Coroner is requesting information directly from the CQC. Skills for 
Care draw on CQC recommendations and guidance when developing our products 
and services, and signpost stakeholders across the sector to CQC documentation. 

Pertinent to this request, Skills for Care notes CQC’s recommendations relating to 
Regulation 18: Staffing, which include (but are not limited to): ‘Providers must ensure 
that they have an induction programme that prepares staff for their role’ and ‘Where 
appropriate, staff must be supervised until they can demonstrate required/acceptable 
levels of competence to carry out their role unsupervised’.   

We also note CQC recommends that ‘Staff should be supported to make sure they 
can participate in: [....], Other learning and development opportunities required to 
enable them to fulfil their role. This includes first aid training for people working in the 
adult social care sector’. 

Care Certificate  

The Care Certificate is an agreed set of 15 standards that define the knowledge, 
skills and behaviours expected of specific job roles in the health and social care 
sectors.   

It was introduced in 2015 and was jointly developed by Skills for Care, Health 
Education England and Skills for Health under a grant commission from the 
Department of Health and Social Care.  Skills for Care host a wide range of Care 
Certificate resources on our website. 

The 15 standards are: 

1.  Understand your role 
2.  Your personal development 
3.  Duty of care 
4.  Equality and diversity 
5.  Work in a person-centred way               
6.  Communication 
7.  Privacy and dignity 
8.  Fluids and nutrition 
9.  Awareness of mental health, dementia and learning disabilities 
10. Safeguarding adults 
11. Safeguarding children 
12. Basic life support 
13. Health and safety 
14. Handling information 
15. Infection prevention and control 

Standard 12: Basic life support states:  The learner must be able to carry out basic 
life support.  This BSL training must meet the UK Resuscitation Council Guidelines. 

 
 
 
 
 
 The Care Certificate is not a mandatory programme for care providers.  Instead, it is 
considered to be the minimum training, supervision and assessment that staff ‘new 
to care’ (health and adult social care) should receive as part of a robust induction 
and before they start to deliver care out of the line of sight of more experienced 
workers. 

In practice, it is employers who determine the point at which a worker can work out 
of the line of sight of more experienced workers based on their assessments of their 
workers’ competence and the skills required in particular situations. 

Level 2 Adult Social Care Certificate Qualification 

Earlier this year Skills for Care was commissioned by the Department of Health and 
Social Care (DHSC) to develop a specification for the development of a new Care 
Certificate qualification based on the existing Care Certificate standards.   

Awarding organisations are currently developing the qualification in preparation for a 
June 2024 launch.  

The qualification will not be mandatory.  And it will not replace an employer’s 
responsibility to provide appropriate support, training, professional development, 
supervision and appraisal as necessary to enable the worker to carry out the duties 
they are employed to perform. Employers are expected to provide a robust induction 
as part of this process. 

It's the employer’s responsibility to ensure staff undergo any mandatory training as 
part of an induction, and relevant mandatory training cycles.  

As with the current version of the Care Certificate, those undertaking the qualification 
will need to understand procedures for responding to accidents, sudden illness and 
providing basic life support. 

Learning from Events 

Skills for Care’s digital module, Learning from Events, may be of interest to the 
Coroner. It is available at no cost to the sector and is based on the PAcE model 
(People, Activity and Environment).  The module aims to support leaders and 
managers carry out learning reviews to holistically explore adverse events and 
create actions plans to avoid repeat incidents.    

Learning from Deaths Review Programme (LeDer): 

We acknowledge that due to the circumstances of Mr Waite’s death, a LeDer review 
would be completed and that recommendations from this may also be considered if 
directed to Skills for Care or it leads to sector-wide mandated training or regulatory 
changes. If this was to happen, Skills for Care would align our guidance and advice 
to reflect updated messaging from CQC and HSE etc. 

Coroner’s Concerns 

To reiterate, Skills for Care recommends that every frontline care worker within a 
CQC regulated services should be supported to receive First Aid training, including 

 
 
 basic life support as part of their initial induction to the sector, and ensure these skills 
and competences are regularly refreshed beyond that. 

We recognise the importance that First Aid training, including Basic Life Support, and 
encourage providers to adhere to the CQC’s Regulation 18: Staffing 
recommendation: ‘Where appropriate, staff must be supervised until they can 
demonstrate required/acceptable levels of competence to carry out their role 
unsupervised’.  

In this context, we believe that this would mean that staff scheduled to work alone, 
out of sight of more experienced colleagues must receive the training before being 
left unsupervised, rather than before they start working in a care environment. 

Whilst Skills for Care is committed to influencing improvements in the standards and 
the quality of personalised care across the adult social care sector, as an 
independent charitable body, we are not able to mandate or enforce what training is 
undertaken. 

We hope this information and advice is useful to any further actions. Skills for Care 
would be happy to engage further on this matter with your office, the CQC and the 
provider should you deem that helpful. 

Our deepest sympathies again to the friends, family and carers of Mr Waite. 

Yours sincerely 

Deputy CEO 

Skills for Care