Frederick Boyd

Inquest Index

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SECTION A – Responses

Document

Date

Author

Pages

Regulation 28 Response - 
CQC

Regulation 28 Response - 
The Lakes Care Centre 

22/07/2024

A1 – A6

11/06/2024

A7 – A10

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 HSCA Further Information 

Alison Mutch OBE 

Via email:

22 July 2024 

Our Reference: CAS-381929-X7C5W2 
Your reference: 32900408 

Dear HM Senior Coroner Alison Mutch OBE, 

Prevention  of  future  death  report  following  inquest  into  the  death  of  Frederick 
Martin Gerard Boyd 

Thank  you  for  sending  CQC  a  copy  of  the  prevention  of  future  death  report  issued 
following the sad death of Frederick Martin Gerard Boyd. 

We note the legal requirement upon the Care  Quality Commission to respond to your 
report within 56 days, by the 27 June 2024 and would like to thank you again for agreeing 
to an extension for response until 26 July 2024. 
The registered provider  of  The Lakes Care Centre  is The Lakes Care  Centre Limited. 
They have been registered with CQC as a service provider since 25 August 2023.   

The provider’s location, The Lakes Care Centre is located 

. At the time of Mr Boyd’s death, the provider was registered for the 
regulated activities: ‘Accommodation for persons who require nursing or personal care’ 
and ‘Treatment of disease, disorder or injury’. 

The Lakes Care Centre does not currently have a manager who is registered with CQC 
to oversee and manage the delivery of the regulated activities at this location, in line with 
the condition imposed on this provider’s registration for this location, stating that they must 

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  submitted 
have a registered manager in post. The current home manager, 
applications  to  register  with  CQC  on  25  February  2024  and  6  March  2024.  These 
applications have been rejected by CQC’s registration team as being incomplete and a 
new application has not yet been received or processed by CQC. The previous registered 
manager, 
, was registered with CQC between 25 August 2023 and 13 October 
2023  to  manage  the  regulated  activities  at  The  Lakes  Care  Centre  under  the  current 
provider The Lakes Care Centre Limited. 

The role of the CQC & Inspection methodology 

The role of the Care Quality Commission (CQC) as an independent regulator is to register 
health and adult social care service providers in England and to assess/inspect whether 
or not the fundamental standards  set out in the Health and Social Care Act 2008, and 
amendments, are being met.   

The  regulatory  approach  used  during  previous  inspections  of  The  Lakes  Care  Centre 
considered  five  key  questions.  They  asked  if  services  were  Safe;  Effective;  Caring; 
Responsive; and Well Led.  Inspectors used a series of key lines of enquiry (KLOEs) and 
prompts  to  seek  and  corroborate  evidence  and  reassurance  of  how  the  provider 
performed  against  characteristics  of  ratings  and  how  risks  to  service  users  were 
identified, assessed and mitigated.   

The  regulatory  framework  includes  providers  being  required  to  meet  fundamental 
standards of care; the standards below which care must never fall.  We provide guidance 
to providers on how they can meet these standards (Regulations 4 to 20A of the Health 
and Social Care Act 2008 (Regulated Activities) Regulations 2014).  

On 6 February 2024 CQC’s Operations Network in the North region went live with our 
new Single Assessment Framework. This approach covers all sectors, service types and 
levels and the five key questions remain central to this approach. However, the previous key 
lines of enquiry (KLOEs) and prompts have been replaced with new ‘quality statements’. The 
quality    are  described  as  ‘we  statements’  as  they  have  been  written  from  a  provider’s 
perspective to help them understand what we expect of them. They draw on previous work 
developed  with  Think  Local  Act  Personal  (TLAP),  National  Voices  and  the  Coalition  for 
Collaborative  Care  on Making  it  Real.  They set  clear  expectations  of  providers,  based  on 
people’s experiences and the standards of care they expect. We have introduced six new 
evidence categories to organise information under the statements; these are feedback from 
people, feedback from staff and leaders, feedback from partners, our observations, processes 
and outcomes.  This approach will allow CQC to  use a range of information to assess 
providers flexibly and frequently, collect evidence on an ongoing basis and update ratings at 
any time; tailor our assessment to different types of providers and services; score evidence to 
make our judgements more structured and consistent; use site visits and data and insight to 

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 gather evidence to assess quality and produce shorter and simpler reports, showing the most 
up-to-date assessment. 

Background 

We have reviewed all our records and cannot find that we received a statutory notification 
in relation to  Mr Boyd’s death.  Failure to provide statutory notifications in accordance 
with Regulation 16 of the Care Quality Commission (Registration) Regulations 2009 is a 
criminal offence and we have written to the registered provider to request an explanation 
for  their  failure  to  notify  and  will  review  their  response  and  may  take  further  action. 
Subsequently we have contacted the service to request Mr Boyd’s care records so this 

case can be reviewed under our specific incident guidance. 

Regulatory History 

The Lakes Care Centre was registered with CQC under the current provider, The Lakes 
Care  Centre  Limited  on  25  August  2023.  Prior  to  this  the  service  was  managed  by 
Blackcliffe Limited.  

Under the previous provider, Blackcliffe  Limited, there had been  poor compliance with 
relevant  regulations  and  CQC  had  taken  numerous  enforcement  actions  to  drive 
improvement which had ultimately led to the service being rated ‘Inadequate’ overall and 
the  provider  going  into  administration.  An  inspection  undertaken  in  February  2023 
(published 13 April 2023) identified some improvements had been made to the service 
delivered. It was subsequently rated ‘requires improvement’ overall with conditions placed 
on the registration. This allowed the administrators to proceed with a sale of The Lakes 
Care Centre as a going concern. The Lakes Care Centre Limited commenced operating 
the home under a licence to manage agreement on 18 July 2023 and the sale of the home 
was completed on 22 September 2023. 

The  Lakes  Care  Centre  has  been  in  a  multiagency  concern  (MAC)  process  led  by 
Tameside  MBC  since  23  May  2022.  This  process  brings  together  key  stakeholders 
including commissioners, health services, CQC and the provider to oversee and support 
the  provider  and  to  share  information  both  positive  and  negative  about  the  service 
delivered and progress towards improvements in performance.  

On  the  22  April  2024  CQC  began  an  assessment  of  The  Lakes  Care  Centre  which 
included  on-site  and  off-site  processes.  The  decision  to  assess  was  following  several 
concerns being raised at a MAC meeting in relation to  ongoing safeguarding concerns, 
particularly those in relation to people with nursing needs. As a result, CQC undertook an 

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 assessment looking at all quality statements and evidence categories relating to the key 
questions ‘Is the service safe?’ ‘Is the service effective?’ and ‘Is the service well led?’ At 
the time the assessment commenced The Lakes Care Centre had stopped delivering the 
regulated activity of ‘Treatment of Disease, disorder and injury’ and all people with nursing 
needs had been transferred to alternative placements by 19 April 2024. 

Matters of concern 

1.  The  inquest  heard  evidence  that  there  was  no  clear  system  or  expectation 
regarding the quality of checks on a resident who exhibited signs of being unwell.  

During our assessment of The Lakes Care Centre, inspectors spoke with people who 
used the service and their families. Families were happy and people all felt confident 
that staff would promptly seek support from other healthcare professionals when this 
was required. However, shortfalls in record keeping and systems of oversight meant 
that people were placed at the risk of avoidable harm. Staff were not consistently 
receiving sufficient training and support in their role. There were shortfalls in the training 
records and the systems in place for oversight were not effective to allow for easy 
identification of gaps in training. Not all staff had received regular supervision and there 
were no clear systems of oversight of supervision to ensure staff were suitably 
supported. We identified breaches of Regulation 12 (Safe care and treatment), 
Regulation 18 (Staffing) and Regulation 17 (Governance) of the Health and Social Care 
Act 2008 (Regulated Activities) Regulations 2014.  

On publication of the report of our assessment we will require the registered provider to 
provide an action plan with clear timescales for completion of each action identified and 
will review progress against this action plan in line with our processes.  

2. The evidence before the  inquest was that the documentation in relation to the 
key period was limited and that there appeared to be a limited understanding by 
staff  of  the  level  of  detail  required  and  that  oversight  of  the  quality  of 
documentation by senior managers was limited. 

During our assessment we identified areas for improvement in terms of care plans, risk 
assessments and staff understanding of using Person Centred Software (PCS), the 
electronic care planning and recording system used at The Lakes Care Centre. The 
registered provider was already aware of this and was arranging additional training. As 
stated in our response to Point 1 there were also areas for improvement in relation to 
governance and oversight identified during this assessment, that we will continue to 
monitor and assess on an ongoing basis.   

3. The evidence before the inquest indicated that the system for escalation where 
a patient was unwell was unclear and not understood by staff. 

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 Inspectors did not identify any issues in respect of systems for escalation and staff 
understanding of this during our assessment and on-site activity. Feedback from the 
digital health service, the local clinical assessment service covering all care homes in 
Tameside, was that it was generally being used appropriately. Partner agencies felt 
things were improving overall and were complimentary about the staff working for the 
service who it was felt generally knew service user’s needs.   

At the time of Mr Boyd’s death, The Lakes Care Centre was operating as a nursing 
home, but the service has now ceased to deliver the regulated activity of ‘Treatment for 
Disease, Disorder or Injury’. This means that any service user requiring a nursing 
intervention will be under the care of the district nurses, which CQC believes mitigates 
some risks to the residents of this service as the service users being cared for will 
generally not have such complex health conditions.  

Since the provider has registered to manage the regulated activities at the location there 
have been a number of changes in the management team and structure of the service. 
There had been concerns about the service and the level and speed of improvement 
being made. Partner agencies raised concerns that information had not always been 
escalated effectively and statutory notifications which services are required to send to 
CQC were not always completed. As stated above, we have written to the registered 
provider regarding this matter and will review their response to determine appropriate 
action. 

The provider was in the process of restructuring the management arrangements for the 
two open units when we carried out our recent assessment. Of the two open units, one 
specialised in providing purely residential care and the other specialised in residential 
dementia care. This process had not been completed and we will review the impacts of 
this decision when we next assess the service.  

At the time of our visit there was no registered manager and although the home 
manager intended to register with the CQC, the application had not yet been 
successfully accepted. We will follow this up with the manager and seek to register 
them as soon as possible. 

Yours sincerely, 

Deputy Director of Operations  

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 Network North, CQC 

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