John Howlett

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 
Fax: 

14 November 2024 

Alison Mutch OBE 
HM Senior Coroner 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Via email: 

Our Reference: 
Your reference: 

Dear HM Senior Coroner Alison Mutch OBE, 

Prevention of future death report following inquest into the death of John Francis 
Howlett. 

Thank  you  for  sending  CQC  a  copy  of  the  prevention  of  future  death  report  issued 
following the sad death of Mr Howlett. 

We  note  the  legal  requirement  upon  the  Care  Quality  Commission  to  respond  to  your 
report  within  56  days,  by  the  1  November  2024  and  would  like  to  thank  you  again  for 
agreeing to an extension for response until 29 November 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 Off Boyd Walk, Lakes Road, 
Dukinfield, SK16 4TX. At the time of Mr Howlett’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  has  not  had  a  registered  manager  since  13  October  2023  to 
oversee  and  manage  the  delivery  of  the  regulated  activities  at  this  location,  in 

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 contravention  of  the  condition  imposed  on  this  provider’s  registration  for  this  location, 
stating that they must have a registered manager in post.  

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

Background 

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 We have reviewed all our records and cannot find that we received a statutory notification 
in relation to Mr Howlett’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. 
Previous failings to submit statutory notifications have been subject to enforcement action 
against this registered provider. A review was conducted in respect of the specific incident 
and  there  are  currently  no  reasonable  grounds  to  suspect  a  criminal  offence  of  a 
registered person.  

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.  

Matters of concern 

1.  The inquest heard that on arrival at A and E at Tameside Hospital Mr Howlett 
spent  22  hours  in  a  corridor  despite  suffering  from  an  infection  and  the 
distress  that  this  caused.  The  inquest  was  told  that  this  was  due  to  the 
demands  on  the  department  and  the  challenges  of  moving  patients  onto 

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 wards due to capacity issues. The inquest was told that this was not unique 
to that particular day or indeed to the hospital and was the picture across 
the country at that time. 

We have given careful consideration to this point and have come to the conclusion that 
the  concerns  identified,  namely,  that  Mr  Howlett  spent  22  hours  in  a  corridor  despite 
suffering from a chest infection due to demands on the department and capacity issues, 
a situation not unique to that particular day or hospital, sits outside of CQC remit. We note 
that this report has also been sent to the Secretary of State for Health and Social Care 
and believe they will be of greater assistance in addressing this aspect of your concerns.  

2.  The  evidence  before  the  inquest  indicated  that  the  care  home  in  question 
had been of concern in relation to the care offered to residents for some time. 
It  was  indicated  that  action  plans  were  in  place  particularly  in  relation  to 
safeguarding  concerns  given  the  vulnerability  of  residents.  However, 
despite those steps being in place and the concerns the systems were not 
in place at the care home to robustly monitor his nutritional status and fluid 
intake. He became increasingly frail with decreased physiological reserves 
as a consequence. 

An assessment of The Lakes Care Centre was commenced on 22 April 2024 following 
concerns in relation to the care and support people were receiving. The key questions 
of ‘Is the service safe?’ ‘Is the service effective’ and ‘Is the service well led?’ were 
reviewed and the overall rating for these key questions and the service overall was 
‘requires improvement’.  At the time of this assessment The Lakes Care Centre had 
recently stopped operating as a nursing home but was still registered to deliver the 
regulated activity of ‘Treatment for Disease, Disorder or Injury’. The provider was asked 
to submit a notification to deregister from this regulated activity at the location and this 
was completed on 26 September 2024. The Lakes Care Centre continues to be 
registered for the regulated activity of ‘Accommodation for people requiring nursing or 
personal care’. 

At the assessment in April 2024 inspectors reviewed quality statements under the key 
questions cited above. The quality statements describe the standards of care that 
people should expect. The quality statement scores are the basis of the key question 
scores and ratings. Quality statements are scored out of 4, with 1 being the lowest 
score and 4 being the highest. 

We looked at the quality statements for the key question ‘Is the service effective?’. We 
found that under the quality statement ‘Assessing needs’ whilst assessment processes 

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 required improvement to ensure they were detailed and up to date, staff were aware of 
people’s needs and understood how to meet these needs. This was scored a 2 to 
indicate improvements were needed. 

With regard to the quality statement ‘Delivering evidence-based care and treatment’ we 
received positive feedback from families with people being supported effectively to 
maintain good nutrition and hydration and families noting that people were gaining 
weight. At the time of the assessment, information about people’s needs in relation to 
eating and drinking were found to be in place and food and fluid intake charts were in 
place for those at risk. However, shortfalls in the use of records to demonstrate people 
were having correctly modified diets were found. This quality statement was scored a 2 
to indicate improvements were needed.  

When reviewing the quality statement ‘Supporting people to live healthier lives’ we 
found that suitable processes were in place to refer to partner agencies including 
dietetic services for advice and input into people’s care, although partner agencies 
noted that concerns had not always being escalated in a timely manner. Shortfalls in 
medical partners’ oversight of some people were in the process of being addressed with 
the reintroduction of ‘ward rounds’. This quality statement was scored a 2 to indicate 
improvements were needed. 

The quality statement ‘monitoring and improving’ outcomes noted staff understood the 
importance of promoting and encouraging independence and there were suitable 
processes in place to monitor people’s safety and wellbeing. We noted that there had 
been some shortfalls in how people’s needs were monitored but the necessary 
improvements had been implemented and at the time of assessment these needed time 
to become embedded. This was scored a 3 to indicate the service was meeting our 
expectations under this quality statement.  

The key question ‘is the service safe?’ was reviewed and shortfalls in relation to 
Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 
(Regulated Activities) Regulations 2014 were found due to gaps in how risk was 
managed and mitigated and how lessons were learnt. The quality statement ‘Learning 
culture’ was scored 2 as improvements were needed and the process for analysis of 
incidents where things had gone wrong to ensure learning, was not being used 
effectively to ensure people were kept safe.  

The key question’ Is the service well led?’ was rated ‘requires improvement’ following 
the inspection of April 2024 and a breach of Regulation 17 (Good Governance) of the 
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified. 

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 For the quality statements ‘Governance management and sustainability’ we found that 
although areas for improvement were noted as being needed, the process for oversight 
were not effective and audits did not lead to issues being identified and the required 
action being taken. The quality statement ’Learning, improvement and innovation’ was 
scored 2 to indicate improvements were required. We found that whilst the service was 
committed to making improvements, progress was slow.  

During our assessment we identified areas for improvement in terms of care plans, risk 
assessments and staff understanding of using 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 which will lead to enhanced 
oversight of issues such as fluid monitoring. Areas for improvement in relation to 
governance and oversight were identified during this assessment, that we will continue 
to monitor and assess on an ongoing basis.   

The coroner noted in this regulation 28 report that despite action plans being in place in 
relation to safeguarding concerns, systems were not in place at the care home to robustly 
monitor Mr Howlett’s nutritional status and fluid intake. Our assessment finding indicated 
there continued to be some areas for improvement shortly after Mr Howlett’s death, but 
that action was being implemented and embedded at that time. Enforcement action was 
taken in response to these findings and CQC continue to monitor the service to identify if 
concerns around the service are escalated and require further action.   

The Lakes Care Centre has been subject to close monitoring by both the local authority 
and CQC since 2021. During this time the management of provider oversight has 
changed on several occasions with a new provider, The Lakes Care Centre Limited 
taking ownership and providing the regulated activities since September 2023, with a 
new management structure of systems and processes implemented. The location and 
provider continue to be subject to close scrutiny at the time of this Regulation 28 
response by both CQC and the local integrated care board. 

At the time of Mr Howlett’s death CQC were involved in the MAC process and attended 
a MAC meeting in January 2024 but no significant causes of concerns were identified or 
shared at that time. The following meeting in March 2024 identified more significant 
issues in relation to record keeping and timeliness of progress being made. It was not 
until The Lakes Care Centre had made a decision to stop delivering nursing care that 
the extent of concerns in relation to the delivery of nursing care was noted, at which 
point an inspection of the service was already pending.  

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 Whilst there is evidence there were numerous failings in the care delivered at The 
Lakes Care Centre, which included elements of poor care and poor record keeping as 
noted through the safeguarding investigation, the provider of the service has 
subsequently focused on improving the support and training offered to staff. They are 
also looking at how they work with other professionals (CQC have referred to this in our 
response to your Regulation 28 report regarding Mr Fredrick Boyd) 

At the time of Mr Howlett’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 people being cared for will generally 
not have such complex health conditions.  

At the time of our visit there was no registered manager in post and there have been 
changes to the home manager. Upon the provider identifying a suitable candidate for 
the registered manager role, an application has been accepted by CQC’s registration 
team and we will seek to register this individual as soon as possible. 

We will continue to monitor the service.    

It is well documented that there have been some shortfalls in the systems and 
processes following the roll out of our new regulatory platform and provider portal. 
There has and continues to be a significant amount of work to make the improvements 
to ensure we have the best oversight of all health and social care services and are 
effective as the regulator.  

Yours sincerely, 

Deputy Director of Operations  

Network North, CQC 

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Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

31st October 2024 

Our ref: 

HM Alison Mutch, 
Coroner’s Court,  
1 Mount Tabor Street, Stockport, 
SK1 3AG 

By email: 

Dear Ms Mutch,  

Thank you for the Regulation 28 report of 6 September 2024, sent to the Secretary of State 
for Health and Social Care about the death of John Francis Howlett. I am replying as the 
Minister with responsibility for urgent and emergency care.       

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Howlett’s 
death, and I offer my sincere condolences to his family and loved ones. The circumstances 
your report describes are very concerning and I am grateful to you for bringing these matters 
to my attention. 

The  report  raises  concerns  about A&E  waiting times  due  to  capacity  issues  at  Tameside 
and Glossop Integrated Care NHS Foundation Trust (TGICFT) and safeguarding concerns 
at The Lakes Care Centre.  

In preparing this response, my officials have made enquiries with NHS England to ensure 
we adequately address your concerns. 

In  relation  to  the  first concern  raised  regarding  A&E  waiting  times  and  capacity  issues,  I 
understand that the TGICFT completed work on re-developing and re-designing its urgent 
care and emergency departments in July 2024.  Actions to support improved waiting times 
have included: 

•  continuation  of  ‘front-door  streaming’,  which  identifies  the  most  appropriate  care 
pathway for each patient at initial assessment.  Patients are streamed from A&E to 
suitable services such as urgent treatment centres, community services, same day 
emergency care and virtual wards to reduce long waits in A&E. 

•  an Urgent Care Transformation Programme which aims to support patient flow. The 
programme has helped the Trust to identify priority areas, such as digitally recording 
of initial time-to-treatment, and has improved waiting times. 

•  a review of the emergency department consultant rota to include 7-day working and 
extended working hours to support safety in the Department, and all waits over 12 
hours are analysed to assess whether clinical harm was caused.  

 
 
 
 
 
 
 
 
 
  
 
 
 
  
  
 
 
 • 

the Trust’s Chief Operating Officer working with Adult Social Care, locality and 
Integrated Care System colleagues to improve discharge from wards to reduce 
numbers of patients in beds with ‘no criteria to reside’. This has also included 
support for front-door processes, for example, the operation of an acute frailty unit 
to avoid hospital admissions for those patients living with frailty. 

These actions have helped support improved patient flow and a positive impact on waiting 
times. 

In relation to the second concern raised regarding safeguarding at The Lakes Care Centre, 
any form of abuse or neglect is unacceptable. The department has legislation and policies 
in place for escalating concerns if provider action plans are not addressing safeguarding 
issues effectively. And under section 42 of the Care Act, the local authority must carry out 
safeguarding enquiries.    

The Care Quality Commission (CQC) has also been sent a copy of this Regulation 28 
report and will be issuing a response. The CQC regulate providers of health and social 
care services to ensure they are providing safe and effective care, and will consider if any 
regulatory action needs to be taken. 

It is good practice for a local authority’s Safeguarding Adults Board (SAB) to work with 
coroners. You may have already contacted the local SAB about whether they have 
considered Safeguarding Adults Review (SAR). However separately DHSC officials 
reached out to Tameside SAB.   

Tameside explained that a referral has not been made for a SAR because there was 
learning for the home but not for wider partners at the end of a Section 24 Safeguarding 
Adult Enquiry. However, the local authority has been continuing to support The Lakes 
Care Centre to improve their practice working with partner agencies and all actions plans 
are being monitored.   

Further, NHS England has confirmed that The Lakes Care Centre is no longer registered 
for nursing, and a successful transfer of nursing residents has taken place. It is now under 
new management, and work is ongoing to support them to use residential capacity for 
extra needs and increase residential dementia capacity. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

MINISTER OF STATE FOR HEALTH

Care Centre

Regulation 28 — Report to Prevent Future Deaths

Ref: Mr John Francis Howlett — deceased 31* January 2024

Response from The Lakes Care Centre

Narrative:

The Lakes Care Centre, at the time of the incident and when Mr Howlett was admitted and
resided, was under the control and management of The Lakes Care Centre Limited. We were
registered with CQC for Nursing, Residential and Residential with Dementia.

Mr Howlett was supported on our Nursing Unit — Derwent. As reported previously in our
Report to Coroners Court 15"" Jul 2024 which outlined the challenges, we encountered
operating and managing a Nursing Service at The Lakes Care Centre.

We have since de-registered with CQC for Nursing Services. In addition, since September
2024 we have now managed to secure a full operational management team with both
experience and qualifications to enable The Lakes to create reasonable, time focused and
effective Action Plans for Improvement.

We have achieved this by welcoming in the Local Authority Quality Improvement Team. They
have undertaken a Quality Audit (Sep 24). This was in line with CQC style inspection and
covered every aspect of the services we provide.

The outcome of which is closer working relationships with the Local Authority Contract
Compliance Teams, Quality Improvement Team and local NHS ICB.

The new Manager and myself have been busy implementing changes to our in-house
recording systems and care monitoring systems to ensure we identify and action any
changes in residents’ welfare and health at the earliest opportunity.

We had also identified the dual GP services we used were not working well or indeed in
partnership with The Lakes. This resulted in little or poor support on matters such as
nutrition management and identification of any appropriate health care planning to support
our residents.

In November 2024 a new single GP service has been commissioned and we hope this will

improve communication and clinical observation of our residents including weekly ‘ward
rounds’ to identify early sign of improvement or deterioration in their health.

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Al

telahes)—

Care Centre

In addition to our internal improvement plans we have been working with the MAC Process
(Multi Agency Concern) panel made up of professionals form a broad spectrum of
disciplines. We meet monthly to review and assess progress to our improvement goals.

This is now showing major improvement in managing and providing good outcomes for our
residents whilst looking at a process of continue improvement through regular care reviews,
incident reviews and referral on to appropriate services for support in providing a timely and
safer and more effective service to our residents.

We monitor and respond to Service User Feedback, Relatives/Visitor feedback and
professional feedback both positive and negative.

All of the above has seen a reduction in the levels of concern raised about our services,
improvement in outcomes for our residents and a more robust and systematic approach to
reviewing, learning and improving.

To expand on what we have undertaken so far:

a) Started all training from ‘scratch’ to ensure all employees get the same level and
undertraining of what is required in all care and health matters. This is via Team
meetings, individual 1:1 sessions, E Learning and Face to Face training.

b) We are introducing (Sep 24) a new E Learning platform which enables employees to
access mandatory and developmental learning with associated policy and procedures
attached as part of that learning. It also provides much better visibility of employee
learning progress and prompts employees and managers of the expectations in a
timely manner to maximise attendance and outcomes.

c) The New Management Structure is working closely with senior carers about the
ability of the Digital Care Record to assist in ensuring Residents Well Being and the
Hydration Chart is a good example of this.

d) All Senior carers are now using our Digital Care Record daily to monitor and use the
Hydration Tracker to identify any shortfalls or concerns about resident's intake of
fluids. This is then escalated and remedial actions identified and delivered.

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e)

f)

g)

h)

Care Centre

We have begun to nurture again our relationship with the local Infection Prevention
Teams and Contract Monitoring Teams to ‘move’ forward on our performance on a
day-to-day basis and improve the quality of care and support and outcomes for our
residents.

Reduce our reliance on ‘agency staff’ to a level that is lower than at the time of this
residents stay. This helps us be confident in our employees/workers skills and
performance. In addition, we have more day-to-day confidence that our employees
are following our Core Values in everyday practice.

Improve employee morale with clearer direction and support to get things right first
time. Feedback from employees has been excellent since we took over and they are
saying they feel more supported and valued as a team. This is an ongoing
management focus.

Improve resident and family feedback. From some initial surveys and face to face
meetings, the feedback we are getting is that our service is more welcoming, and
more caring. The facilities are described as outstanding and very homely.

Therefore, given all of the above, we hope this helps you understand the progressive steps
we have made since the sad death of Mr Howlett and how we understand the need for clear
and effective care/support to ensure the safety and well-being of all our residents in their
time of need.

Response written by:

Operations Director and Nominated individual (CQC)

On behalf of The lakes Care Centre Limited.

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