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

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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

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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.

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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

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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

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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

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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.

Dear Ms Mutch

Bernard Lyons (Deceased) – Response to Regulation 28 Report

Thank you for your Report in relation to the outcome of the Inquest into Mr Lyons’ death. There are several actions that we have taken as a Local Authority to ensure we avoid these failings in the future.

We have revised our Multi Agency Concern (MAC) process to stipulate that providers are notifying families where there are concerns within the home. We will be launching the guidance with providers in the coming months, following sign off through our governance process. In the meantime, the MAC meetings stress the importance of notifying families where there are any concerns within homes that are subject to the MAC process.

Our CQC colleagues are always invited to the MAC meetings and we also have regular monthly meetings with the lead inspector to impart any concerns that we may have.

We have undertaken a review of the Commissioning Team structure and increased the number of quality monitoring officers. We are implementing more robust contract monitoring processes and quality visits to ensure we are working with all the homes more closely. This will identify any issues that may arise in relation to staffing, recruitment and language barriers.

All providers will be expected to attend Provider Forum Meetings so that we can share any learning and be made aware of any potential issues by providers.

Dear Ms Mutch,

Thank you for the Regulation 28 report of 9 April 2025 sent to the Secretary of State for Health & Social Care about the death of Bernard Lyon. 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 Mr Lyon’s death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

Your report raises concerns over a shortage of managers at Mr Lyon’s care home; a reliance on agency staff who had difficulty communicating with residents at the care home; the Care Quality Commission (CQC) failing to attend multi-agency meetings about care home issues; a failure to communicate to Mr Lyon’s family the fact that the care home was subject to an improvement plan; significant delays in handovers from ambulances to the emergency department (ED) at Tyneside Hospital; significant demand on the hospital’s ED and a subsequent difficulty in complying with national sepsis guidance; and delays in transferring patients from the ED due to ongoing demand for beds elsewhere in the hospital.

In preparing this response, my officials have made enquiries with NHS England and the CQC to ensure we adequately address these concerns. I am aware that the CQC is replying to you separately.

Matters of concern:

1) Care home has too few managers

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Local authorities in England have a responsibility under the Care Act 2014 to meet eligible needs and statutory guidance directs them to ensure there is a sufficient workforce across adult social care. Many local authorities commission care from private providers. Regulated providers have a key role in safeguarding adults. All staff are subject to employer checks and controls, and employers must satisfy themselves regarding the skills and competence of their staff.

The CQC monitors how well providers are safeguarding service users. As part of their regulatory regime, the CQC checks that care providers have effective systems to help keep adults safe from abuse and neglect. Meanwhile, the CQC is also assessing how well local authorities in England are delivering adult social care by looking at how they are performing against their duties under Part 1 of the Care Act 2014.

The government recognises the scale of reforms needed to make sure the ASC sector has sustainable workforce growth and improve the retention of the domestic workforce. This is why we are working with the Department of Work and Pensions (DWP) to promote ASC careers to jobseekers. DWP supports employers in the ASC sector with their recruitment through a range of activities including Jobs Fairs, hosting employers in Jobcentres and promoting their vacancies. We are also introducing the first ever Fair Pay Agreement for care professionals and expanding the Care Workforce Pathway (the first-ever national career structure for ASC) which outlines a structured route for care workers to move into management roles. It helps care homes identify and nurture internal talent by showing staff how to advance from entry-level roles to registered manager positions.

Care homes can use the Care Workforce Pathway to plan for succession, identify skills gaps, and develop a leadership route. It creates a more stable and resilient management structure. The pathway includes or aligns with accredited training programmes specifically designed for aspiring and current managers such as the Level 5 Diploma in Leadership and Management in Adult Care, and Level 5 Award in Understanding Digital Leadership in Adult Social Care. It can include leadership training, safeguarding responsibilities, regulatory compliance, and HR skills.

The department is also providing funding under the Learning and Development Support Scheme (LDSS) to support learning and development for ‘non-regulated care staff’, including deputy and CQC registered managers and agency staff. The list of training courses and qualifications eligible for funding includes a range of leadership, management and digital skills learning opportunities, which are designed to equip care managers with the skills they need to develop and lead effectively.

2) Reliance on agency staff

Your inquiry highlighted concerns about the English language proficiency of the agency staff hired by the care home. Care work involves personal relationships, and communication is a crucial component of that relationship. It is imperative that employers appropriately assess English language proficiency during their recruitment processes, regardless of whether they are recruiting domestically or from outside of the UK.

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On 12 May 2025, the Home Office published the Immigration White Paper: Restoring Control over the Immigration System, setting out changes to English language requirements across the immigration system and international recruitment in ASC.

We recognise proficiency in language is essential to living and working in the UK and therefore new English language requirements will be introduced across a broader range of immigration routes for both main applicants and their dependants. For Skilled Workers and workers where a language requirement already applies, the threshold will increase from B1 to B2 (independent user). A new English language requirement will also be introduced for all adult dependants of workers and students at level A1. The Home Office will set out further detail on these changes in due course.

In line with the government’s policy to reduce reliance on international recruitment in ASC overseas recruitment for ASC will end. This will be implemented at the earliest opportunity to change the Immigration Rules in 2025. There will be a transition period until 2028 where in-country switching for those already in the UK with working rights will continue to be permitted. This will be kept under review.

Since February 2022, the main route for care workers wishing to come to the UK has been through the Health and Care visa. To qualify for this visa, individuals must demonstrate that they meet the B1 standard of English language, details of the levels can be found at: The CEFR Levels - Common European Framework of Reference for Languages (CEFR). This is an eligibility requirement of all work and study visas and will not necessarily mean that the individual has the proficiency and skills required to do a specific role.

Furthermore, there are immigration routes which permit individuals to work in the UK without needing to seek approval from the Home Office and do not have an English language requirement. Care providers are therefore responsible for ensuring that the individual speaks and reads to the standard required for the job.

To support providers, the department published the ‘International recruitment toolkit for social care providers’ (International recruitment toolkit - March 2024), outlining the English language requirements and steps employers should take during the recruitment process to ensure care workers have the correct level of English language competence.

In this case, there is insufficient information provided to ascertain if the agency staff employed by the nursing home will have had to prove their English language proficiency as part of the route in which they came to the UK. On 12 May 2025, the Home Office published the Immigration White Paper: Restoring Control over the Immigration System, setting out changes to English language requirements across the immigration system and international recruitment in ASC.

It is the responsibility of a care provider to ensure the individuals they hire are suitable for the role. As part of CQC inspections, they will assess whether providers are employing 'fit and proper' staff to deliver care. Under regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, employers are required to only employ ‘fit and proper’ staff to provide care and treatment appropriate to their role. To meet this regulation, providers must ensure they have robust recruitment procedures, undertaking relevant checks, and a procedure for ongoing monitoring of staff to make sure they remain A11

able to carry out the duties required of them. Employees are required to have the qualifications, competence, skills and experience which are necessary for the work to be performed by them. Failure to comply with regulations about quality and safety can result in regulatory action being taken against providers and registered managers.

3) CQC not attending MAC meetings – this will be addressed by the CQC separately.

4) No process to let families know about care home being subject to an improvement plan.

Your inquest found that there is currently no process in place for routinely communicating to families when a care home is subject to a CQC action plan. Action plans are documents which CQC ask a provider to produce when significant concerns are identified at a service. The action plan is produced by and is the responsibility of the provider – CQC receive it for awareness and monitoring purposes. Action plans can already be made publicly available, if requested through the provision the Freedom of Information Act (FOIA). When CQC receive FOIA requests for action plans, they consider the public interest in disclosure on a case-by-case basis. Hyde Nursing Home had been rated “Requires Improvement” by CQC in February 2023. As set out in Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20A states that providers must ensure that their CQC rating(s) are displayed conspicuously and legibly at each location delivering a regulated service and, on their website, (if they have one). CQC can prosecute for a breach of this regulation or a breach of part of the regulation. I agree that greater transparency of action plans may be helpful for families. I have asked my officials to explore this further.

5) Handover delays in the Emergency Department which was also too busy to follow national sepsis guidance

Your report raises matters of concern in relation to patient demand and capacity impacting on waiting times at Tameside General Hospital’s emergency department (ED), including the time taken for patients to be handed over from ambulance services. The Government recognises that waiting times for urgent and emergency care services have been below the high standards that patients should expect in recent years. The Government is also clear that patients should expect and receive the highest standard of service and care from the NHS. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes. To start with, in the Autumn Budget, the Government announced an extra £22.6 billion in day-to-day spending in 2025/26 for the NHS compared to 2023/24, to help cut NHS waiting times. An additional £3.1bn further capital investment over 2 years will provide the highest real-terms capital budget since before 2010. A12

We recognise that investment alone won’t be enough and are determined that it must go hand in hand with fundamental reform. On 5 December 2024, the Government published the Plan for Change (available here: https://www.gov.uk/government/publications/plan- forchange), that set the mandate for the direction of change with clear milestones in five national missions, including building an NHS that is fit for the future. On 30 January 2025, the Government published ‘Road to recovery: the government's 2025 mandate to NHS England’, that clearly set out delivery instructions for the NHS through the prioritisation of five key objectives aimed at driving reform within the NHS. Improving A&E and ambulance wait time was a prioritised objective in the mandate to specifically address the current challenges facing urgent and emergency care. On the same day NHS England published the 2025-26 planning guidance that contained the operational delivery detail for local NHS systems The planning guidance included an implementation target for improving A&E waiting times compared to 2024/25, with a minimum of 78% of patients seen within 4 hours in March 2026 and increasing the proportion of patients admitted, discharged, and transferred from an emergency department within 12 hours across 2025/26 compared to 2024/25. NHS England is also working with systems to reduce ambulance handover delays, working towards delivering hospital handovers within 15 minutes with joint working arrangements that ensure no handover takes longer than 45 minutes.

6) Build-up of patients in ED due to demand for beds and delayed discharges.

My officials are informed by NHS England that work is underway to tackle these issues locally. The Trust has completed improvement work on its re-developed and re-designed Urgent Care and Emergency Departments. This has allowed better flow through the hospital and allows for more effective communication between teams which has positively impacted on waiting times. In addition, the Trust continues to make use of front door streaming for patients arriving into the Emergency Department, with diversion to other services such as Urgent Treatment Centre (UTC), community services, Same Day Emergency Care (SDEC), and virtual wards. The success of this activity can be seen in the increase in patients ‘streamed’ to the urgent treatment centre. An Urgent Care Transformation Programme is also in place to develop “front door” initiatives to support flow in the Department which feeds into the locality system Urgent Care Delivery Board. Priority areas have been identified which has seen improvement in wait times in ED which include the implementation of digital recording of initial time-to-treatment. The report recognises that the pressure in the emergency department is affected by bed capacity at the trust and delayed patient discharges. I am pleased to note that an additional ward has been funded and opened in November 2024 at Tameside General Hospital to provide additional capacity and is now fully operational. The ward also includes a discharge lounge that supports an increase in patient flow, meaning that patients who are medically fit for discharge are being discharged to the right place more quickly. More broadly, this government is committed to tackling delayed discharges through the Better Care Fund (BCF), and its revised policy framework, published on 31 January 2025. For 2025-26, approximately £9 billion is committed to the BCF. This includes around £3.3 billion provided to local authorities and £5.6 billion to integrated care boards, both of which A13

must be pooled through the BCF. As part of this, the NHS and local authorities are required to set goals on discharge performance against which their performance can be monitored. In June 2025, to accompany the additional investment in the NHS, the Government will publish its 10-Year Health Plan which will set out the radical reforms for the NHS. The health plan will focus on ensuring three big reform shifts in the way our health services deliver care. First, from ‘hospital to community’ to bring care closer to where people live. Second, from ‘analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future. I hope this response is helpful. Thank you for bringing these concerns to my attention.