Margaret Bailey

Care Quality 
Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Andrew Bridgman  
HM Assistant Coroner 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

                                                                                                      24 October 2025 

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: 

toileting (including in relation to menstruation) 

•  eating or drinking (including the administration of parenteral nutrition) 
• 
•  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. 

Yours sincerely 

Operations Manager, CQC Network North

Minister of State for Care  

39 Victoria Street  
London  
SW1H 0EU 

23rd December 2025 

Andrew Bridgman 
HM Assistant Coroner  
1 Mount Tabor Street  
Stockport  
SK1 3AG 

Dear Mr Bridgman,  

Thank you for the Regulation 28 report of 3 September 2025 sent to the Secretary of State 
of the Department of Health and Social Care about the death of Mrs Margaret Bailey. I am 
replying as the Minister with responsibility for Adult Social Care (ASC).          

Firstly, I would like to say how saddened I was to read of the circumstances of  Margaret 
Bailey’s  death  and  I  offer  my  sincere  condolences  to  their  family  and  loved  ones.  The 
circumstances your report describes are  concerning and I am grateful to you for bringing 
these  matters  to  my  attention.  Please  accept  my  sincere  apologies  for  the  delay  in 
responding to this matter. Thank you for the additional time provided to the department to 
provide a response to the concerns raised in the report.  

Your report raises concerns over there being “no algorithm for the call handler to follow to 
triage the client, setting out why the client appears unwell and to then determine a course of 
action” and highlights that the call handler “tends to be an assistant manager/manager but 
with no medical background” and that the “direction of the conversation is simply left to the 
‘office’”.  Additionally,  your report states  that  the  carer reporting  that  Margaret  was  unwell 
had “no ability 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.”  

In  preparing  this  response,  my  officials  have  made  enquiries  with  the  Care  Quality 
Commission (CQC) to ensure we adequately address your concerns. I am aware that CQC 
has also provided you a response on this matter.  

 
  
 
 
 
 
  
 
 
 
 
 
  
  
 
  
 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’. 

The Care Quality Commission (CQC) requires all providers to have, at a minimum, baseline 
training  and  policies  in  place  for  staff  to  follow  in  the  event  a  person  in  receipt  of  care 
experiences a deterioration in health or change in  their condition or needs. This includes 
ensuring appropriate escalation channels are in place for staff to follow. Where a provider 
does use an algorithm to support the triage of phone calls, in instances such as these, CQC 
may  review algorithms,  alongside  a  provider’s  general operating  systems  and day-to-day 
processes.  

Having looked at Mrs Bailey’s case, we understand CQC consider the initial guidance given 
by the staff in the office to be reasonable based on the symptoms observed, and presence 
of a live-in carer. Based on this assessment, and CQC’s existing regulation of providers, we 
do not consider further action would prevent a similar instance.  

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.  

As set out in CQC’s scope of registration, any service offering care and treatment provided 
by  or  under  the  supervision  of  a  healthcare  professional  would  need  to  register  for  the 
regulated  activity  Treatment  for  disease,  disorder  or  injury  (TDDI),  or  have  delegated 
healthcare arrangements in place, neither of which apply in this case.  

As  noted  in  the  response  from  CQC,  the  domiciliary  care  organisation  providing  care  for 
Maragaret Bailey is registered to provide the regulated activity Personal care, which includes 
physical assistance with tasks such as personal hygiene, continence care and eating. The 
personal care regulated activity does not require staff to be clinically trained to perform tasks 
such as taking and monitoring temperature readings.  

We recognise that the circumstances of Margaret Bailey’s death, where a reduced gag reflex 
and inability to protect the airway led to fatal aspiration, highlight the significant risks posed 

 
 
 
 
 
 
 
 by choking hazards for individuals with complex care needs. To address this, we will ask 
NICE  to  consider,  through  its  established  topic  selection  process,  the  development  of  a 
national standard on the prevention and management of choking hazards in domiciliary and 
residential care settings. Clear guidance would help ensure carers are better equipped to 
identify and respond to choking risks, ultimately improving safety for vulnerable adults.  

Thank you for bringing these concerns to my attention.    

Yours sincerely, 

MINISTER OF STATE FOR CARE