CQC
Regulator / Inspectorate
Noted
The CQC acknowledges the concerns, noting that the care home in question is now dormant and outlining CQC's role and inspection methodology. They state that the Secretary of State for Health and Social Care is better placed to address concerns about pressures on the ED. (AI summary)
View full response
Dear HM Senior Coroner Alison Mutch OBE,
Prevention of future death report following inquest into the death of Bernard Lyon. Thank you for sending CQC a copy of the prevention of future death report issued following the sad death of Bernard Lyon.
We note the legal requirement upon the Care Quality Commission to respond to your report within 56 days, by the 4 June 2025.
The registered provider of Hyde Nursing Home is Treetops Nursing Home Limited. They have been registered with CQC since 1 June 2022. At the time of Mr Lyon’s admission the home had a registered manager, who was registered on 14 December 2023.
The provider’s location, Hyde Nursing Home, is located at Grange Road South, Gee Cross, Tameside SK14 5NB. The provider is registered for the regulated activities: Accommodation for persons who require nursing or personal care and Treatment of disease, disorder or injury. The home is currently dormant, the registered provider having given notice and facilitated transfer of service users to new accommodation by 20 June
2024.
HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA
Telephone: 03000 616161 Fax: 03000 616171 A1
2
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 are being met.
The regulatory approach used during the inspections of Hyde Nursing Home considers five key questions. They ask if services are 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 performs against characteristics of ratings and how risks to people are identified, assessed and mitigated.
The regulatory framework includes providers being required to meet fundamental standards of care, 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 Operations Network North went live with our new Single Assessment Framework. This approach covers all sectors, service types and levels and the five key questions have stayed 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.
Background
We have reviewed all our records and cannot find that we received a statutory notification advising of Mr Lyon’s admission to Tameside General Hospital on 22 January 2024, or his subsequent death. We were made aware of this case on receipt of your Future Death report. Regulatory History
Hyde Nursing Home was re-registered under the registered provider Treetops Nursing Home Limited on 1 June 2022. The last comprehensive inspection prior to the change in registration took place in 2018, when the service was rated good. A further targeted inspection took place on 1 July 2021 as part of CQC's response to the COVID-19 pandemic when we looked at the preparedness of care homes in relation to infection A2
3
prevention and control. No issues were found in respect of the systems for preventing and controlling infections at that time.
The first inspection under the registered provider Treetops Nursing Home Limited took place on 27 and 28 July 2022. We undertook this inspection because we had received concerns regarding staff, the management of medicines, health and safety, and staff recruitment. In response we undertook a focused inspection to review the key questions: Is the service safe?, Is the service effective? Is the service well led? We found breaches of Regulation 11, Need for consent, Regulation 15, Premises and equipment, Regulation 18, Staffing and Regulation 19, Fit and proper persons employed of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 (The 2014 Regulations). We served requirement notices for these breaches and a warning notice for a further breach of Regulation 17, Good governance, as we considered that the failings in multiple areas were a result of poor oversight and governance. The service was overall rated requires improvement.
We carried out a further inspection at Hyde Nursing Home on 19 and 20 January 2023, to follow up on the breaches of regulation. We found improvements had been made and the service was no longer in breach of any of the regulations and had complied with the warning notice. We did however make recommendations to 1) review the dependency tool for staffing to ensure it took account of the environmental challenges, Hyde Nursing Home being a very large home, spread over 4 units, and 2) to ensure audits were completed across all the units to ensure lessons learned could be disseminated across the whole home. Although we did evidence improvements, the overall rating remained requires improvement, as we believed there was further work to be done in embedding the changes that had been made.
Matters of concern
1. The care home in question was recognised as having too few managers for it to be effectively managed but was allowed to continue to operate and was seeking to expand.
Care homes such as Hyde Nursing Home are required to have a registered manager as a condition of their registration. Appointed managers must apply and satisfy us about their fitness and meet with the other requirements of the relevant regulations and enactments. Through this system of registration, we ensure that only those people who are judged to be fit and are likely to provide and manage good quality care that meets the needs of people, are authorised to do so.
A3
4
There are no further stipulations within the Health and Social Care Act about the numbers of managers a registered provider must have, and it would be a matter for the provider to determine the staffing and management arrangements of the home to ensure they were structured in a way that enabled the safe delivery of the regulated activities. CQC’s role is then to assess through assessment and inspection, the efficacy of those arrangements and whether leadership and governance is sufficiently robust.
At the time of Mr Lyon’s admission to the home, CQC had no serious concerns about the home, based on our previous inspection, but were continuing to monitor progress through engagement with the local authority’s MAC process.
2. The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and communicate with residents.
Regulation 18, Staffing, of the 2014 Regulations, states that the registered provider must ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirement. Use of agency staff within the adult social care sector is common, where the provider has been unable to attract or retain sufficient in-house staff, employed directly by them.
Where CQC identify that agency staff are being employed, we will seek evidence that the registered provider has carried out due diligence to be satisfied that the staff have been suitably trained and have the requisite skills, including command of English. Where we find this is not the case, we will raise this with the provider and this may constitute a breach of the regulation, with associated regulatory action.
3. The inquest was told that the Local Authority regularly held MAC meetings to look at care home issues from a multi-agency perspective. The CQC rarely attended the meetings. As a consequence, the flow of information to the CQC was reduced.
I note in ’s statement from the evidence bundle, that he said, “The council and Care Quality Commission continue to liaise with each other about registered providers in Tameside, with regular meetings and sharing of information”.
Within the Escalation Plan and Accountability Framework for Care Provision Tameside, section 1.8 states, “The CQC, as a statutory regulator of care provision, has an independent alert process. This is a valuable system for commissioners. CQC will always be informed of any health or social care concerns via the direct contact meetings and A4
5
established communication pathways with the LA Commissioning Team and NHS GMIC (Tameside) commissioners”.
CQC are surprised that this is the view of the Local Authority, as we have regular meetings with both the commissioners and the quality team and will always attend MAC meetings where there are concerns.
4. The inquest was told that there was no process to let a family know of concerns that agencies had about a care home or that it was subject to an improvement plan. This meant families were being left to make decisions about where to place family members unaware of the actual situation and concerns.
We have given careful consideration to this point and note that this report has also been sent to Tameside Metropolitan Borough Council who may be of greater assistance in addressing this aspect of your concerns. We note that Mr Lyon was receiving Continuing Healthcare Funding and therefore his partner was in contact with healthcare professionals who would be in a position to advise her about the suitability of any placement. Our reports are published on our websites and the report from our inspection in June 2023 made reference to the fact that the home was working towards an action plan.
5. The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock-on impact on the ability of the ambulance service to respond to calls. The inquest was told that TGH had made efforts to improve the turnaround time, and it was currently at just an average time of 23.22 minutes. There was further evidence that TGH were not unusual amongst hospitals in the Northwest with the turnaround time at other hospitals running at over 1 hour.
6. The Emergency Department at TGH was extremely busy on the day Mr Lyon arrived which was not unusual. The sheer volume of patients who were seriously ill meant there was a delay in him being given antibiotics in accordance with this need. The Trust had taken steps to address this, but it was accepted that where there was a significant demand on an ED compliance with the national sepsis guidance was far more difficult to achieve.
7. The Emergency Department at TGH was extremely busy on the day Mr Lyon arrived which was not unusual. The sheer volume of patients who were seriously ill meant there was a delay in him being given antibiotics in A5
6
accordance with this need. The Trust had taken steps to address this, but it was accepted that where there was a significant demand on an ED compliance with the national sepsis guidance was far more difficult to achieve.
Resourcing of the ED service and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust and available data. Waiting times and other national targets receive close monitoring. CQC carry out inspections of urgent and emergency services in those trusts that are performing poorly in line with national ED targets. In comparison to other Manchester trusts and similar trusts in the Northwest, Tameside and Glossop Integrated Care NHS Foundation Trust has not flagged as one of the poorest performers in relation to ambulance waits outside the department and waiting times within the department. Performance data is always discussed in engagement with the Trust. In terms of improvements to urgent and emergency services, the Trust has recently opened the rebuilt emergency department which now has a larger footprint and the capacity to see more patients simultaneously. This is expected to improve waiting areas and lessen waiting times for patients and an
8.2% improvement for 4-hour performance from March 2024-March 2025 (2nd best in Greater Manchester) has so far been achieved. Ambulance handover times are also showing improvements with a significant reduction in 12 hour breaches. The improvements within ED and reduced waiting times for patients should improve the likelihood of patients receiving antibiotics for suspected sepsis in a more timely way.
8. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available.
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 and believe they will be of greater assistance in addressing this aspect of your concerns, the picture being complex with competing demands on budgets and the subsequent effects on patient care. CQC continue to monitor through engagement with the Trust and draw on our findings from CQC’s national NHS patient survey programme and statutory reports, our inspection activity, bespoke research into people’s experiences, insight from key stakeholders, and the evidence that our expert staff have collected throughout the year about the quality and safety of services in all areas of health and care. Our inspections in urgent and emergency care across the country found issues around triage and patient flow that affect A6
7
care for all patients. This includes the link between delayed hospital discharges and availability of home-based care and care home beds, which is acutely apparent. We highlighted these issues in our State of Care report published 25 October 2024 and will continue to comment on progress and lack thereof, in our future reports.
To conclude we can confirm that if Hyde Nursing Home remains closed for a year (until 20 June 2025) and the current provider is unable to secure a sale, CQC will move to deregister the service in line with our current processes.
Should you require any further information then please do not hesitate to contact us.
Prevention of future death report following inquest into the death of Bernard Lyon. Thank you for sending CQC a copy of the prevention of future death report issued following the sad death of Bernard Lyon.
We note the legal requirement upon the Care Quality Commission to respond to your report within 56 days, by the 4 June 2025.
The registered provider of Hyde Nursing Home is Treetops Nursing Home Limited. They have been registered with CQC since 1 June 2022. At the time of Mr Lyon’s admission the home had a registered manager, who was registered on 14 December 2023.
The provider’s location, Hyde Nursing Home, is located at Grange Road South, Gee Cross, Tameside SK14 5NB. The provider is registered for the regulated activities: Accommodation for persons who require nursing or personal care and Treatment of disease, disorder or injury. The home is currently dormant, the registered provider having given notice and facilitated transfer of service users to new accommodation by 20 June
2024.
HSCA Further Information Citygate Gallowgate Newcastle upon Tyne NE1 4PA
Telephone: 03000 616161 Fax: 03000 616171 A1
2
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 are being met.
The regulatory approach used during the inspections of Hyde Nursing Home considers five key questions. They ask if services are 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 performs against characteristics of ratings and how risks to people are identified, assessed and mitigated.
The regulatory framework includes providers being required to meet fundamental standards of care, 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 Operations Network North went live with our new Single Assessment Framework. This approach covers all sectors, service types and levels and the five key questions have stayed 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.
Background
We have reviewed all our records and cannot find that we received a statutory notification advising of Mr Lyon’s admission to Tameside General Hospital on 22 January 2024, or his subsequent death. We were made aware of this case on receipt of your Future Death report. Regulatory History
Hyde Nursing Home was re-registered under the registered provider Treetops Nursing Home Limited on 1 June 2022. The last comprehensive inspection prior to the change in registration took place in 2018, when the service was rated good. A further targeted inspection took place on 1 July 2021 as part of CQC's response to the COVID-19 pandemic when we looked at the preparedness of care homes in relation to infection A2
3
prevention and control. No issues were found in respect of the systems for preventing and controlling infections at that time.
The first inspection under the registered provider Treetops Nursing Home Limited took place on 27 and 28 July 2022. We undertook this inspection because we had received concerns regarding staff, the management of medicines, health and safety, and staff recruitment. In response we undertook a focused inspection to review the key questions: Is the service safe?, Is the service effective? Is the service well led? We found breaches of Regulation 11, Need for consent, Regulation 15, Premises and equipment, Regulation 18, Staffing and Regulation 19, Fit and proper persons employed of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 (The 2014 Regulations). We served requirement notices for these breaches and a warning notice for a further breach of Regulation 17, Good governance, as we considered that the failings in multiple areas were a result of poor oversight and governance. The service was overall rated requires improvement.
We carried out a further inspection at Hyde Nursing Home on 19 and 20 January 2023, to follow up on the breaches of regulation. We found improvements had been made and the service was no longer in breach of any of the regulations and had complied with the warning notice. We did however make recommendations to 1) review the dependency tool for staffing to ensure it took account of the environmental challenges, Hyde Nursing Home being a very large home, spread over 4 units, and 2) to ensure audits were completed across all the units to ensure lessons learned could be disseminated across the whole home. Although we did evidence improvements, the overall rating remained requires improvement, as we believed there was further work to be done in embedding the changes that had been made.
Matters of concern
1. The care home in question was recognised as having too few managers for it to be effectively managed but was allowed to continue to operate and was seeking to expand.
Care homes such as Hyde Nursing Home are required to have a registered manager as a condition of their registration. Appointed managers must apply and satisfy us about their fitness and meet with the other requirements of the relevant regulations and enactments. Through this system of registration, we ensure that only those people who are judged to be fit and are likely to provide and manage good quality care that meets the needs of people, are authorised to do so.
A3
4
There are no further stipulations within the Health and Social Care Act about the numbers of managers a registered provider must have, and it would be a matter for the provider to determine the staffing and management arrangements of the home to ensure they were structured in a way that enabled the safe delivery of the regulated activities. CQC’s role is then to assess through assessment and inspection, the efficacy of those arrangements and whether leadership and governance is sufficiently robust.
At the time of Mr Lyon’s admission to the home, CQC had no serious concerns about the home, based on our previous inspection, but were continuing to monitor progress through engagement with the local authority’s MAC process.
2. The home relied on agency staff who the inquest was told struggled to have sufficient grasp of the English language to understand instructions given and communicate with residents.
Regulation 18, Staffing, of the 2014 Regulations, states that the registered provider must ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirement. Use of agency staff within the adult social care sector is common, where the provider has been unable to attract or retain sufficient in-house staff, employed directly by them.
Where CQC identify that agency staff are being employed, we will seek evidence that the registered provider has carried out due diligence to be satisfied that the staff have been suitably trained and have the requisite skills, including command of English. Where we find this is not the case, we will raise this with the provider and this may constitute a breach of the regulation, with associated regulatory action.
3. The inquest was told that the Local Authority regularly held MAC meetings to look at care home issues from a multi-agency perspective. The CQC rarely attended the meetings. As a consequence, the flow of information to the CQC was reduced.
I note in ’s statement from the evidence bundle, that he said, “The council and Care Quality Commission continue to liaise with each other about registered providers in Tameside, with regular meetings and sharing of information”.
Within the Escalation Plan and Accountability Framework for Care Provision Tameside, section 1.8 states, “The CQC, as a statutory regulator of care provision, has an independent alert process. This is a valuable system for commissioners. CQC will always be informed of any health or social care concerns via the direct contact meetings and A4
5
established communication pathways with the LA Commissioning Team and NHS GMIC (Tameside) commissioners”.
CQC are surprised that this is the view of the Local Authority, as we have regular meetings with both the commissioners and the quality team and will always attend MAC meetings where there are concerns.
4. The inquest was told that there was no process to let a family know of concerns that agencies had about a care home or that it was subject to an improvement plan. This meant families were being left to make decisions about where to place family members unaware of the actual situation and concerns.
We have given careful consideration to this point and note that this report has also been sent to Tameside Metropolitan Borough Council who may be of greater assistance in addressing this aspect of your concerns. We note that Mr Lyon was receiving Continuing Healthcare Funding and therefore his partner was in contact with healthcare professionals who would be in a position to advise her about the suitability of any placement. Our reports are published on our websites and the report from our inspection in June 2023 made reference to the fact that the home was working towards an action plan.
5. The evidence given to the inquest indicated significant delays in the handover from the ambulance to the ED team. This was due to pressure on the ED but meant that ambulances were tied up for longer than necessary and then had a knock-on impact on the ability of the ambulance service to respond to calls. The inquest was told that TGH had made efforts to improve the turnaround time, and it was currently at just an average time of 23.22 minutes. There was further evidence that TGH were not unusual amongst hospitals in the Northwest with the turnaround time at other hospitals running at over 1 hour.
6. The Emergency Department at TGH was extremely busy on the day Mr Lyon arrived which was not unusual. The sheer volume of patients who were seriously ill meant there was a delay in him being given antibiotics in accordance with this need. The Trust had taken steps to address this, but it was accepted that where there was a significant demand on an ED compliance with the national sepsis guidance was far more difficult to achieve.
7. The Emergency Department at TGH was extremely busy on the day Mr Lyon arrived which was not unusual. The sheer volume of patients who were seriously ill meant there was a delay in him being given antibiotics in A5
6
accordance with this need. The Trust had taken steps to address this, but it was accepted that where there was a significant demand on an ED compliance with the national sepsis guidance was far more difficult to achieve.
Resourcing of the ED service and others across the country is a known risk and is subject to ongoing monitoring through engagement with the Trust and available data. Waiting times and other national targets receive close monitoring. CQC carry out inspections of urgent and emergency services in those trusts that are performing poorly in line with national ED targets. In comparison to other Manchester trusts and similar trusts in the Northwest, Tameside and Glossop Integrated Care NHS Foundation Trust has not flagged as one of the poorest performers in relation to ambulance waits outside the department and waiting times within the department. Performance data is always discussed in engagement with the Trust. In terms of improvements to urgent and emergency services, the Trust has recently opened the rebuilt emergency department which now has a larger footprint and the capacity to see more patients simultaneously. This is expected to improve waiting areas and lessen waiting times for patients and an
8.2% improvement for 4-hour performance from March 2024-March 2025 (2nd best in Greater Manchester) has so far been achieved. Ambulance handover times are also showing improvements with a significant reduction in 12 hour breaches. The improvements within ED and reduced waiting times for patients should improve the likelihood of patients receiving antibiotics for suspected sepsis in a more timely way.
8. The inquest was told that the build-up of patients and levels of demand in the ED at TGH were not unusual and continued. As an illustration of the ongoing nature of the demand in recent months one patient waited in ED for 3 days for a bed. The delay in transfer was due to an ongoing demand for beds and delayed discharges of patients medically optimised but with no suitable non acute/community provision being available.
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 and believe they will be of greater assistance in addressing this aspect of your concerns, the picture being complex with competing demands on budgets and the subsequent effects on patient care. CQC continue to monitor through engagement with the Trust and draw on our findings from CQC’s national NHS patient survey programme and statutory reports, our inspection activity, bespoke research into people’s experiences, insight from key stakeholders, and the evidence that our expert staff have collected throughout the year about the quality and safety of services in all areas of health and care. Our inspections in urgent and emergency care across the country found issues around triage and patient flow that affect A6
7
care for all patients. This includes the link between delayed hospital discharges and availability of home-based care and care home beds, which is acutely apparent. We highlighted these issues in our State of Care report published 25 October 2024 and will continue to comment on progress and lack thereof, in our future reports.
To conclude we can confirm that if Hyde Nursing Home remains closed for a year (until 20 June 2025) and the current provider is unable to secure a sale, CQC will move to deregister the service in line with our current processes.
Should you require any further information then please do not hesitate to contact us.