CQC
Regulator / Inspectorate
Noted
The Care Quality Commission explains its role and inspection methodology and states that it is outside CQC's scope to amend regulations to allow HCAs to take on medical or nursing observations, noting that the report has also been sent to The Secretary of State for Health and Social Care. (AI summary)
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Dear HM Assistant Coroner, Andrew Bridgman,
Prevention of future deaths report following inquest into the death of Margaret Bailey
Thank you for sending CQC a copy of the prevention of future deaths report issued following the sad death of Margaret Bailey.
We note the legal requirement upon the Care Quality Commission to respond to your report within 56 days, by the 29 October 2025.
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 (Regulated Activities) 2014, and amendments, are being met.
The regulatory approach used during previous inspections of Right at Home Stockport and Didsbury 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 included 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.
Regulatory History Right at Home was registered by CQC on 02 November 2017 to provide the regulated activity of ‘personal care’ which includes physical assistance with tasks such as personal hygiene, continence care and eating. Right at Home Stockport and Didsbury was last inspected on 6 December 2022 where it was rated good in all five key questions. We subsequently carried out a review of the data available to us about Right at Home Stockport & Didsbury on 6 July 2023. We did not find evidence that we needed to carry out an inspection or reassess our rating at that time. We continue to monitor this service through our provider engagement processes and work closely with the local commissioning teams.
Matters of concern
1. On the ‘office’ receiving a call from a carer reporting, as here, that a client appears to be unwell there is no algorithm for the call handler (who tends to be an assistant manager/manager but with no medical background) to follow to triage the client, setting out why the client appears unwell and to then determine a course of action. The direction of the conversation is simply left to the ‘office’.
We have given careful consideration to this point and note that this report has also been sent to the Secretary of State for Health and Social Care. The Department of Health and Social Care may be of greater assistance in addressing this aspect of your concerns because currently in line with CQC’s Scope of Registration the regulated activity of Personal care is defined as physical assistance given to a person in connection with:
• eating or drinking (including the administration of parenteral nutrition)
• toileting (including in relation to menstruation)
• washing or bathing
• dressing
• oral care
• the care of skin, hair and nails (except for nail care provided by a chiropodist or podiatrist)
On this basis employees are not medically trained, the introduction of an algorithm for call handlers could arguably lead to possible errors in its execution or interpretation. At present there is no nationally recognised framework that home care providers are advised or required to adopt, but CQC would expect all providers to have at least a baseline level of training and policy in place for staff to follow in the event of deterioration in health and presentation of people in receipt of care, and appropriate escalation channels.
In Mrs Bailey’s case the initial guidance given by the staff in the office appears reasonable based on one bout of diarrhoea and the suggestion that Mrs Bailey looked unwell, especially as a live in carer was in situ.
Skills for Care do have training resources for staff working in adult social care and training is an area closely monitored and discussed with providers when CQC are carrying out assessments of quality and safety. RESTORE2 is a physical deterioration and escalation tool for care homes, people who live in supported living and supporting people who live in their own homes. It’s based on nationally recognised methodologies. The RESTORE2 Mini for carers tool is intended to be used by carers, where the care and support is being undertaken by a paid or unpaid carer, a care worker, a personal assistant or support worker.
The training slides include a background on the ‘soft signs’ of deterioration, and what we mean by ‘deterioration’; including the benefits of using deterioration tools, the importance of understanding when someone becomes unwell, what factors could ensure the best outcome, annual health checks, spotting signs of cancer and what to do in a medical emergency. The RESTORE2 Mini for carers tool helps staff find out if the person they are supporting is feeling unwell. SBARD (Situation, Background, Assessment, Recommendation and Decision) is a way of communicating when someone is unwell, especially with medical professionals. Spotting the signs when a person becomes unwell
2. There was no ability for the carer reporting that Margaret was unwell to carry out any basic observations, neither before the call to the office nor after it, in order that Margaret could be monitored as per the advice given or to at least provide a baseline for monitoring, not even a temperature reading. Most family homes, caring for children or physically vulnerable adults, would have at least a thermometer, and perhaps a pulse oximeter, maybe even a blood pressure machine.
Our scope of registration setting out the parameters that constitute Personal care mean that home care staff are not required to be clinically trained and would not be expected to carry out activities such as taking, recording and interpreting vital signs. Therefore, it would be unlikely that homecare agencies would provide such equipment. Exceptions to this would be if the provider was also registered to provide the regulated activity of Treatment for disease, disorder or injury (TDDI) or staff were
performing tasks under delegated healthcare arrangements which they were not in this case.
Delegation occurs when a nurse employed by one registered provider requests a member of staff employed by a different registered provider to carry out a nursing task on their behalf. In this example, this could be a district nurse requesting a staff member at a home care agency (HCA) to take and record a person’s vital signs on their behalf. In this example, the nurse is employed by a district nursing service provider, which is registered for the regulated activity of Treatment of Disease, Disorder or Injury (TDDI). The nurse is delegating the tasks to someone employed at the HCA, a different regulated provider, which is not registered for TDDI. The HCA, whose employees are accepting the delegated tasks, is not considered to be carrying on the regulated activity of TDDI and therefore does not need to register for it. The definition of TDDI under Schedule 1 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out: The provision of treatment for a disease, disorder or injury that is carried out by or under the supervision of a health care professional, or a team which includes a health care professional (or a social worker, or a team which includes a social worker, where the treatment is for a mental disorder). A list of applicable health care professionals (HCPs) is also set out under schedule 1 and includes nurses. This means TDDI is carried out by or under the supervision of a health care professional. In this case a nurse. Where a task is delegated, the task is not being carried out by the nurse themselves, it is being done on their behalf. Neither is the task being completed under the supervision of the nurse. This is because they do not work for the same registered provider.
Therefore, carers employed by HCAs could carry out this type of task, and if they were, this type of equipment would be available to them, but it would be the exception to the rule and would be in line with the assessed needs of the person receiving care. It should also be noted that the registered provider may be at risk of providing regulated activities they are not registered for if staff are carrying out tasks that would fall in the scope of TDDI and this would be a potentially prosecutable offence.
In summary it is outside CQC scope and powers to amend the regulations in order that HCAs who are limited by the definition of Personal care would be allowed to take on medical or nursing observations and we have noted that you have also sent this report to The Secretary of State for Health and Social Care who may be better placed to address this issue if they believe a change in the Regulations is required.
Should you require any further information then please do not hesitate to contact us.
Prevention of future deaths report following inquest into the death of Margaret Bailey
Thank you for sending CQC a copy of the prevention of future deaths report issued following the sad death of Margaret Bailey.
We note the legal requirement upon the Care Quality Commission to respond to your report within 56 days, by the 29 October 2025.
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 (Regulated Activities) 2014, and amendments, are being met.
The regulatory approach used during previous inspections of Right at Home Stockport and Didsbury 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 included 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.
Regulatory History Right at Home was registered by CQC on 02 November 2017 to provide the regulated activity of ‘personal care’ which includes physical assistance with tasks such as personal hygiene, continence care and eating. Right at Home Stockport and Didsbury was last inspected on 6 December 2022 where it was rated good in all five key questions. We subsequently carried out a review of the data available to us about Right at Home Stockport & Didsbury on 6 July 2023. We did not find evidence that we needed to carry out an inspection or reassess our rating at that time. We continue to monitor this service through our provider engagement processes and work closely with the local commissioning teams.
Matters of concern
1. On the ‘office’ receiving a call from a carer reporting, as here, that a client appears to be unwell there is no algorithm for the call handler (who tends to be an assistant manager/manager but with no medical background) to follow to triage the client, setting out why the client appears unwell and to then determine a course of action. The direction of the conversation is simply left to the ‘office’.
We have given careful consideration to this point and note that this report has also been sent to the Secretary of State for Health and Social Care. The Department of Health and Social Care may be of greater assistance in addressing this aspect of your concerns because currently in line with CQC’s Scope of Registration the regulated activity of Personal care is defined as physical assistance given to a person in connection with:
• eating or drinking (including the administration of parenteral nutrition)
• toileting (including in relation to menstruation)
• washing or bathing
• dressing
• oral care
• the care of skin, hair and nails (except for nail care provided by a chiropodist or podiatrist)
On this basis employees are not medically trained, the introduction of an algorithm for call handlers could arguably lead to possible errors in its execution or interpretation. At present there is no nationally recognised framework that home care providers are advised or required to adopt, but CQC would expect all providers to have at least a baseline level of training and policy in place for staff to follow in the event of deterioration in health and presentation of people in receipt of care, and appropriate escalation channels.
In Mrs Bailey’s case the initial guidance given by the staff in the office appears reasonable based on one bout of diarrhoea and the suggestion that Mrs Bailey looked unwell, especially as a live in carer was in situ.
Skills for Care do have training resources for staff working in adult social care and training is an area closely monitored and discussed with providers when CQC are carrying out assessments of quality and safety. RESTORE2 is a physical deterioration and escalation tool for care homes, people who live in supported living and supporting people who live in their own homes. It’s based on nationally recognised methodologies. The RESTORE2 Mini for carers tool is intended to be used by carers, where the care and support is being undertaken by a paid or unpaid carer, a care worker, a personal assistant or support worker.
The training slides include a background on the ‘soft signs’ of deterioration, and what we mean by ‘deterioration’; including the benefits of using deterioration tools, the importance of understanding when someone becomes unwell, what factors could ensure the best outcome, annual health checks, spotting signs of cancer and what to do in a medical emergency. The RESTORE2 Mini for carers tool helps staff find out if the person they are supporting is feeling unwell. SBARD (Situation, Background, Assessment, Recommendation and Decision) is a way of communicating when someone is unwell, especially with medical professionals. Spotting the signs when a person becomes unwell
2. There was no ability for the carer reporting that Margaret was unwell to carry out any basic observations, neither before the call to the office nor after it, in order that Margaret could be monitored as per the advice given or to at least provide a baseline for monitoring, not even a temperature reading. Most family homes, caring for children or physically vulnerable adults, would have at least a thermometer, and perhaps a pulse oximeter, maybe even a blood pressure machine.
Our scope of registration setting out the parameters that constitute Personal care mean that home care staff are not required to be clinically trained and would not be expected to carry out activities such as taking, recording and interpreting vital signs. Therefore, it would be unlikely that homecare agencies would provide such equipment. Exceptions to this would be if the provider was also registered to provide the regulated activity of Treatment for disease, disorder or injury (TDDI) or staff were
performing tasks under delegated healthcare arrangements which they were not in this case.
Delegation occurs when a nurse employed by one registered provider requests a member of staff employed by a different registered provider to carry out a nursing task on their behalf. In this example, this could be a district nurse requesting a staff member at a home care agency (HCA) to take and record a person’s vital signs on their behalf. In this example, the nurse is employed by a district nursing service provider, which is registered for the regulated activity of Treatment of Disease, Disorder or Injury (TDDI). The nurse is delegating the tasks to someone employed at the HCA, a different regulated provider, which is not registered for TDDI. The HCA, whose employees are accepting the delegated tasks, is not considered to be carrying on the regulated activity of TDDI and therefore does not need to register for it. The definition of TDDI under Schedule 1 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out: The provision of treatment for a disease, disorder or injury that is carried out by or under the supervision of a health care professional, or a team which includes a health care professional (or a social worker, or a team which includes a social worker, where the treatment is for a mental disorder). A list of applicable health care professionals (HCPs) is also set out under schedule 1 and includes nurses. This means TDDI is carried out by or under the supervision of a health care professional. In this case a nurse. Where a task is delegated, the task is not being carried out by the nurse themselves, it is being done on their behalf. Neither is the task being completed under the supervision of the nurse. This is because they do not work for the same registered provider.
Therefore, carers employed by HCAs could carry out this type of task, and if they were, this type of equipment would be available to them, but it would be the exception to the rule and would be in line with the assessed needs of the person receiving care. It should also be noted that the registered provider may be at risk of providing regulated activities they are not registered for if staff are carrying out tasks that would fall in the scope of TDDI and this would be a potentially prosecutable offence.
In summary it is outside CQC scope and powers to amend the regulations in order that HCAs who are limited by the definition of Personal care would be allowed to take on medical or nursing observations and we have noted that you have also sent this report to The Secretary of State for Health and Social Care who may be better placed to address this issue if they believe a change in the Regulations is required.
Should you require any further information then please do not hesitate to contact us.