James Astley

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

Via email: 

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Telephone: 
Fax: 

12  November 2024 

Our Reference: 
Your reference: 

Dear HM Senior Coroner Alison Mutch OBE, 

Prevention  of  future  death  report  following  inquest  into  the  death  of  Mr  James 
Astley 

Thank you for sending Care Quality Commission (CQC) a copy of the prevention of future 
death report issued following the sad death of Mr Astley. 

We note the legal requirement upon the CQC to respond to your report within 56 days, 
that being by 5 November 2024. Please accept our sincere apologies for the delay due 
to one of our staff being on sick leave from work.   

The registered provider of Downshaw Lodge is Qualia Care Limited. Qualia Care Limited 
has been registered with CQC as a service provider since 11 November 2016.   

The provider’s location, Downshaw Lodge, is located in Downshaw Road, Ashton Under 
Lyne,  OL7  9QL.  At  the  time  of  Mr  Astley’s  death,  the  provider  was  registered  for  the 
regulated activities of ‘Accommodation for persons who require nursing or personal care’ 
and ‘Treatment of disease, disorder or injury’. 

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 The role of the CQC & Inspection methodology 

The role of CQC as an independent regulator is to register health and adult social care 
service providers in England and to assess whether or not the fundamental standards as 
set out in the Health and Social Care Act 2008, and amendments, are being met. CQC 
also have civil and criminal enforcement powers should providers be assessed to have 
breached the fundamental standards set.    

The  regulatory  approach  used  during  previous  inspections  of  Downshaw  Lodge 
considered  five  key  questions.  They  asked  if  the  service  was  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 obtain 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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 CQC first became aware of the death of Mr Astley on 30 January 2024 when a statutory 
notification of death was submitted by the provider. This was assessed by an inspector 
at  the  time  who  sought  further  information  due  to  the  notification  indicating  that  a 
safeguarding  referral  had  been  raised  against  the  care  home.  The  safeguarding 
investigation records were reviewed and although areas of learning were noted for the  
provider, CQC was assured that the necessary actions were already in progress. These 
actions included ensuring all people living at the home had up to date and relevant care 
plans as well as training for staff around the use of the digital health service in order to 
effectively escalate health concerns.  

Downshaw Lodge has been under the multi-agency concerns (MAC) process since the 
provider Qualia Care Limited appointed an administrator on 18 October 2022. The last 
MAC meeting CQC attended in May 2024 raised no concerns about the care people were 
receiving. CQC was advised that work was planned to ensure all staff had completed the 
care certificate, there were plans in place to manage the challenge of  recruiting staff to 
health and social care roles, to review and update care plans and that Downshaw Lodge 
were working well with local authority quality improvement and commissioning teams.  

Regulatory History 

At the time of Mr Astley’s death there was no registered manager in post  The previous 
registered  manager  had  deregistered  from  the  role  on  12  June  2023.    A  manager 
registered with CQC as the registered manager of Downshaw Lodge on 5 June 2024 but 
has subsequently left this role although no application to deregister has currently been 
received. 

The first inspection of Downshaw Lodge was completed in November 2018. The overall 
rating for the service was  ‘requires improvement’ and the key questions ‘Is the service 
safe?’  and  ‘Is  the  service  well  led?’  were  found  to  require  improvement,  with  the  key 
questions ‘Is the service effective?’ ‘Is the service caring?’ and ‘Is the service responsive?’ 
all  being  rated  good.  At  that  time  breaches  of  The  Health  and  Social  Care  Act  2008 
(Regulated Activities) Regulations 2014 were identified. The provider was found to be in 
breach of Regulation 12 (Safe care and treatment) due to shortfalls in the management 
of medicines and infection prevention and control, and Regulation 17 (Good governance), 
due to systems for audits and checks not being effective.  

The next comprehensive inspection of Downshaw Lodge was commenced on 9 January 
2020  and  the  service  was  rated  good  in  all  five  key  questions.  Previous  breaches  of 
regulation found during the inspection of 2019 had been resolved.  

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 CQC  last  visited  the  service  to  complete  a  targeted  inspection  looking  at  infection 
prevention  and  control  on  17  February  2022  as  part  of  the  response  to  the  Covid  19 
pandemic. No concerns were identified at that time. 

Matters of Concern 

1.  The inquest heard evidence that Mr Astley was at significant risk due to poor 
nutrition  and  fluid  intake.  However,  the  MUST  documentation  was  not 
correctly completed and the overall quality of fluid and nutrition charts was 
poor.  As  a  consequence,  he  became  increasingly  frail  and  the  risk  to  his 
overall wellbeing and physiological reserves continued.   

CQC were made aware of the sad death of Mr Astley in a  notification submitted by the 
provider (via the home manager) on 30 January 2024. This notification informed CQC not 
only of Mr Astley’s death but also of the safeguarding concerns raised by the family at the 
point Mr Astley was admitted to hospital, in relation to which a strategy meeting had been 
arranged for February 2024. CQC reviewed the minutes from the strategy meetings as 
part of the initial triage of this notification. This meeting was held on 22 February 2024 via 
teams. The strategy meeting focused on a number of areas including:  

• 

• 

• 

the use or lack thereof of a hospital passport or red bag scheme when Mr Astley 
was admitted to hospital,  
the  accuracy  of  care  plans  and  risk  assessments,  with  areas  of  shortfall  being 
found  in  the  medication  care  plan,  choking  risk  assessment  and  nutritional  risk 
assessment,  
lack  of  contact  with  external  professionals  as  Mr  Astley’s  condition  declined, 
including the speech and language therapy team and dietitian,  

•  and failure to utilise the digital health systems.  

The strategy meeting found that there was evidence of relevant referrals being made and 
followed  up  although  this  was  impacted  by  the  holiday  period.  The  safeguarding 
investigation found evidence that weekly weights for Mr Astley were being completed and 
recorded in a weight folder, which up until the 5 December 2023 had been reasonably 
stable.  Mr  Astley’s  weight  had  deteriorated  between  the  5  December  when  it  was 
recorded  as  47.1kg  and  1  January  2024  where  it  was  recorded  as  being  43.9kg.  The 
dietitian had been contacted on 22 December 2023 and confirmed they would review in 
3-4 weeks. The strategy meeting also looked at concerns in relation to the calling of an 
ambulance. The finding was that a call came from the home on 3 January 2024 at 12:02 
and an update was provided at 13.47 to inform that the GP was making a home visit.  The 
safeguarding minutes noted ‘GP had attended and re-assessed and initially stated that 

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 he  could  be  treated  at  home,  however  when  the  GP  returned  to  the  surgery,  he 
recontacted the care home and instructed the nurse to recall an ambulance to take Mr 
Astley to hospital.’ No evidence of a direct call from the GP was found.  

Learning  was  identified  for  the  home  at  the  point  of  the  strategy  meetings  including 
education sessions for staff in relation to the use of the digital health service in Tameside, 
the  use  of  hospital  passports  and  red  bag  scheme  to  aid  the  transfer  of  important 
information  as  people  transfer  between  services  and  clinical  meetings  and  reflective 
supervision with staff in relation to record keeping and care planning. The final action from 
the  strategy  meeting  was  that  all  covert  medication,  care  plans,  best  interest  and  GP 
discussions  would  be  reviewed  by  the  home  to  ensure  all  paperwork  was  correct  and 
documented. Since this strategy meeting was held the home continued to be engaged 
with a MAC process with monthly or bi-monthly meetings being held with key stakeholders 
including the local authority commissioning team, safeguarding team, the home manager 
and  representatives  from 
indicate 
the  provider.  Records 
improvements have been made and the situation at Downshaw Lodge is positive.  

these  meetings 

from 

Following  the  issuing  of  the  Regulation  28  report  to  Downshaw  Lodge,  CQC  have 
reviewed  the  response  and  learning  from  the  provider  and  sought  further  assurances. 
The provider has shared their response to the Regulation 28 report which included action 
taken  in  regard  to  documentation,  oversight,  communication  and  training.  We  have 
reviewed example documentation shared by the provider as part of the assurance given 
including care records and systems for oversight and analysis. There are indications that 
the necessary processes for appropriate assessment and documentation are available 
for use.  

Subsequent to the Regulation 28 preventing future death report CQC have commenced 
an assessment at Downshaw Lodge to ensure the required changes have been made, 
especially in regard to ensuring staff have received the training and support needed to 
complete accurate assessment of people’s needs, take appropriate action and following 
care  plans  in  line  with  people’s  needs  to  ensure  all  care  needs are  met,  and maintain 
accurate and contemporaneous needs. This assessment was commenced on 16 October 
2024. Once this has been completed a report will be published on the CQC website with 
our findings. This can be found on the link  

https://www.cqc.org.uk/location/1-4019291170/reports 

2.  Overall documentation at the home was limited and lacked detail 

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 CQC have reviewed Mr Astley’s care plans and what daily records were available. There 
were  a  number  of  shortfalls  regarding  the  levels  of  detail,  frequency  and  accuracy  of 
recording. CQC have reviewed 2 weeks of daily records in relation to Mr Astley eating 
and drinking  for the period  of  December  2023.  The  service  has  been unable  to  locate 
other records relating to this time period, in particular we have not  been able to review 
the daily records in relation to Mr Astley’s hospital admission where the evidence is that 
there was a dramatic deterioration in Mr  Astley’s health and presentation.  The records 
reviewed indicated that Mr Astley had been monitored regarding his eating and drinking 
and was supported and encouraged to eat and drink by staff throughout the day. Some 
documentation was not available for review as the provider was not able to locate these. 
The quality of the records varied, and it was not possible to determine to what extent Mr 
Astley’s  nutritional  needs  were  met,  although  records  indicate  he  was  prescribed  a 
supplement drink to increase his nutritional intake on a daily basis.  Mr Astley appeared 
to  have  had  a  fluid  target  of  2000ml  per  day.  It  was  unclear  whether  this  was  an 
appropriate  target  given  Mr  Astley’s  weight  and  frailty  and  subsequently  was  rarely 
achieved on the records reviewed. However, the fluids accepted were often in excess of 
1200ml  based  on  the  records  available  for  review.  As  noted  above  regarding  the 
safeguarding strategy meeting, the provider had identified and accepted improvements 
were  needed  and  implemented  an  action  plan  which  has  been  reviewed  at  the  MAC 
meetings led by the local authority.  

When CQC receives information in relation to an incident of this kind, we consider what 
action we need to take; firstly in relation to whether the information received suggests that 
there may be ongoing risk which requires CQC to inspect a service and secondly whether 
the information received suggests criminal enforcement action should be considered. As 
noted earlier an inspection of the service has been commenced on the 16 October 2024 
to review any matters in relation to ongoing risk and our findings will be published once 
the  process  has  been  concluded.  CQC  have  also  undertaken  an  initial  assessment  in 
respect  of  this  death  to  determine  whether  criminal  enforcement  action  should  be 
considered.  The assessment has involved reviewing information available regarding Mr 
Astley’s care, including information from the inquest and information provided by the care 
home provider. At this time, the initial assessment has concluded that there is no evidence 
of  a  registered  provider  level  failure  and  therefore  the  threshold  at  which  criminal 
enforcement would be considered has not been met in this matter.  

An inspection of Downshaw Lodge was commenced on 16 October 2024. As part of this 
inspection  and  assessment  of  the  service,  CQC  will  review  documentation  within  the 
home  to  assess  whether  it  is  accurate,  up  to  date  and  sufficiently  detailed  to  ensure 
people’s  needs  are  met.  Our  finding  will  be  published  on  the  CQC  website  when  the 
process is completed at https://www.cqc.org.uk/location/1-4019291170/reports 

Yours sincerely, 

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 Deputy Director of Operations 
Network North, CQC 

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Drakes Court

(> Qualia Care i

7 ia 7 Birmingham
(in administration) B47 6JR

HM Coroner Manchester South
Coroner’s Court

1 Mount Tabour Street
Stockport

SK1 3AG

Date: 4 November 2024

Dear Sirs,
Re: Regulation 28 Report into the death of James Astley

We write further to your report made under Regulation 28 of the Coroners and Justice
Act 2009 dated 10 September 2024.

At the outset we, and everyone at Downshaw Lodge (‘The Home’), would like to express
our condolences to Mr Astley’s family and friends on their loss.

Please take this as our formal response to the concerns raised by His Majesty’s Senior
Coroner, Alison Mutch OBE, regarding:

e the quality of record keeping and, in particular, that relating to fluid and nutrition
documentation at The Home; and
e understanding of the MUST system to inform the delivery of care at the Home.

We confirm that steps and actions have been taken by the Home to address these
concerns as is outlined below.

By way of background, the Registered Manager commenced employment at the Home
in early December 2023 following an induction into the service. In December 2023, the
Regional Manager identified a need for improvement in the completion of
documentation by staff, and an action plan was developed. Due to the concerns
identified, a Quality Manager subsequently completed an internal IMPACT audit in
January 2024.

The key areas of concern highlighted in the internal IMPACT audit were:

« Food intake records were generally completed well, but where pureed meals
were provided, they lacked details about the meal contents. A general term,
“blended meal’, was used instead of specifying the ingredients.

e There was limited evaluation of food and fluid intake records to ensure that
residents had adequate nutritional intake and were receiving a varied diet.

www.qualiacare.co.uk | Registered in England No. 10060267

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e Whilst the majority of assessments were completed correctly, a nutrition risk
assessment, a Waterlow assessment, and a MUST were noted to have
been scored incorrectly.

Actions taken to address concerns:

Following the audit, and prior to service of the Regulation 28 report, the Home
implemented several measures to improve record-keeping and ensure that the errors
identified do not recur. Further detail is provided below.

Additionally, regular meetings have taken place with multiple agencies to discuss The
Home's progress and share information. These meetings occur monthly and include the
following attendees: the Team Manager of Tamside (who chairs the meeting), the Home
Manager, the Regional Manager, the Clinical Lead for Continuing Healthcare and Neuro
Rehabilitation, Individualised Commissioning Nurses, the Head of Individualised
Commissioning and Quality Improvement, the Safeguarding Lead, representatives from
Digital Health, District Nurses, the Infection Prevention Officer, and the Contract
Performance Officer.

The agenda for these meetings includes the following:

1. Updates on the agreed priority areas.

2. Update on administration.

3. Feedback from reviews and visits conducted by each stakeholder, focusing on the
agreed priorities and any new issues identified.

4. Input from residents, caregivers, and families.

5. Commissioning updates regarding visits and communication with the provider about
any concerns.

6. Updates on Care Quality Commission (CQC) notifications.

7. Updates on communication strategies.

8. Decisions on further actions required or recommendations, including the escalation
or de-escalation of issues.

MUST Training and Competency:

On 31 January 2024, all nurses and senior staff completed a mandatory training
workshop on the Malnutrition Universal Screening Tool (MUST). The training covered
the correct calculation of MUST scores using the BAPEN calculator. Evidence of
attendance, course details, and syllabus are attached for the benefit of HM Coroner as
Exhibit SA/1. We are pleased to report that the current staff team has been open to
learning and has demonstrated a strong commitment to improving their documentation.

Nutritional Monitoring:
At the end of January 2024, the Registered Manager conducted a full nutritional analysis
of all residents’ weights. Any resident experiencing significant weight loss was flagged,

and their care plan updated. A copy of the Resident MUST Care Plan is attached for
the benefit of HM Coroner as Exhibit SA/2.

www.qualiacare.co.uk | Registered in England No. 10060267

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Since January 2024, at the end of each month, the Registered Manager is provided with
a report on residents’ weight. Again, any resident experiencing significant weight loss is
flagged, and their care plan updated. An example of the monthly report is attached for
the benefit of HM Coroner as Exhibit SA/3.

The Chef at The Home is kept appraised of changes to resident care plans in order that
action can be taken to meet the nutritional needs of residents identified as being at risk.
This includes, for example, fortifying food or preparing tailored meals.

Staff at the Home have ready access to all resident care plans and the Registered
Manager also conducts daily walkarounds to ensure that care plans, including nutritional
needs, are being adhered to.

Regional Manager’s Oversight:

Weekly visits to the Home have been conducted since January 2024 (an continue as at
today’s date) by the Regional Manager iii to ensure that nutritional
monitoring arrangements are being effectively implemented. These visits involve
reviewing high-risk residents’ MUST scores, ensuring they are accurately calculated,
and verifying that care plans contain appropriate detail for managing residents’ dietary
needs.

Training and Compliance
All staff have undergone comprehensive training in key areas:

e Fluid and Nutrition Training: This course covers the principles of hydration,
nutrition, and food safety and ensures that staff understand how to provide
adequate nutrition in line with care plans.

» Documentation and Record-Keeping Training: This course reinforces the
importance of accuracy, clarity, and completeness in documentation.

e MUST Training: as detailed above. Refresher training will be completed
annually at the home for all new starters.

The above training programs ensure that staff members accurately document dietary
and fluid intake, escalate concerns about significant weight loss, and follow the
appropriate procedures to mitigate risks, such as referring residents to a dietician when
necessary. The courses also include guidance on the completion of the ‘Resident 7-day
Booklet’ which documents the following criteria in accordance with the individuals’
identified risks:

Dietary intake
choking risk

IDDSI level

Review of food intake
Fluid intake

Target: ... mls
Review of fluid intake
Review of output
Handovers

www.qualiacare.co.uk | Registered in England No. 10060267

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All staff have now completed the training courses detailed above, and as such, we are
confident they are competent and understand the level of detail required when
completing fluid and nutrition intake charts. The staff also understand how to escalate
when a resident experiences a significant weight loss by reporting to the Registered
Manager and considering the fortification of food or a referral to a Dietician. This is
evidenced through frequent ‘dip-sampling’ of care records which confirm records are
now completed correctly to the required standard.

A list of all training courses provided to staff is detailed in the Training Matrix which is
provided for the benefit of HM Coroner as Exhibit SA/4.

Oversight and Additional Improvements:

Since the death of Mr. Astley, we have introduced further improvements to enhance
The Home’s performance:

e Regular spot checks and ‘dip-sampling’ of care records are now
conducted by the management team. This process ensures compliance
with documentation standards and identifies any need for additional staff
training.

e Fluid and food intake charts are closely monitored, and detailed
handovers take place at every shift change so as to ensure no gaps in
communication.

e Enhanced communication between care staff and kitchen teams has
improved the quality and variety of food provided to residents, with specific
attention given to residents identified as at risk.

« The outcome of the Inquest into the death of Mr. Astley has been shared
with the staff team.

Conclusion

We are committed to ensuring the highest standards of care and have taken substantial
measures to address the concerns identified during the January 2024 IMPACT audit
and those raised by the Senior Coroner. These include improved staff training, regular
reviews of documentation, and enhanced oversight processes.

The steps we have implemented are intended to prevent a recurrence of the issues
observed in Mr. Astley’s case. We firmly believe that these improvements will enhance
the quality of care provided at The Home and ensure that our residents receive safe
and effective care.

We hope this correspondence provides reassurance to the Coroner and Mr. Astley’s
family that the issues identified have been comprehensively addressed and that we are
dedicated to continuous improvement in service quality.

Kind regards,

Managing Director, for and on behalf of Qualia Care Limited
(In Administration)

www.qualiacare.co.uk | Registered in England No. 10060267

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