PFD report

James Astley · Prevention of Future Deaths report

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Issued 10 Sep 2024•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
14

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Poor quality of fluid and nutrition charts
    Part of recurring concern: Inadequate management of patients' nutrition and hydration needs
  2. Limited and insufficiently detailed documentation
  3. Failure to correctly complete MUST documentation
    Part of recurring concern: Inadequate management of malnutrition risk
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. Action

    Conduct an assessment and inspection of Downshaw Lodge to verify required changes, including staff training, accurate needs assessment, care planning, and documentation.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 11 September 2024.
  2. Action

    Provide annual MUST refresher training for all new starters.

    Stated by Qualia Care Limited (In AdministrationStated plannedThe respondent said that this action was planned when they made their response on 11 September 2024.
  3. Action

    Conduct daily management walkarounds and weekly regional oversight visits to verify nutritional care-plan implementation and MUST accuracy.

    Stated by Qualia Care Limited (In AdministrationStated completedThe respondent said that this action was complete when they made their response on 11 September 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing provider actions, multi-agency oversight and available documentation processes were considered sufficient to address identified care and recording risks.

    Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Poor quality of fluid and nutrition charts

Wider context from the report

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

Is this part of a recurring concern?

Yes — Inadequate management of patients' nutrition and hydration needs.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Limited and insufficiently detailed documentation

Wider context from the report

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

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to correctly complete MUST documentation

Wider context from the report

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

Is this part of a recurring concern?

Yes — Inadequate management of malnutrition risk.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct an assessment and inspection of Downshaw Lodge to verify required changes, including staff training, accurate needs assessment, care planning, and documentation.

Verbatim wording from the response

“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”

Source location

Response from CQC
Page 5 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide annual MUST refresher training for all new starters.

Verbatim wording from the response

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

Source location

Response from Downshaw Lodge
Page 3 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct daily management walkarounds and weekly regional oversight visits to verify nutritional care-plan implementation and MUST accuracy.

Verbatim wording from the response

“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.”

Source location

Response from Downshaw Lodge
Page 3 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete an IMPACT audit of documentation, nutrition and fluid-recording practice.

Verbatim wording from the response

“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.”

Source location

Response from Downshaw Lodge
Page 1 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Conduct regular management spot checks and dip-sampling of care records to verify documentation compliance and identify training needs.

Verbatim wording from the response

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

Source location

Response from Downshaw Lodge
Page 4 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Train staff in MUST, fluid and nutrition care, documentation, record-keeping and dietary-risk escalation.

Verbatim wording from the response

“MUST Training and Competency:”

Source location

Response from Downshaw Lodge
Page 2 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monitor fluid and food intake charts and provide detailed handovers at every shift change.

Verbatim wording from the response

“• 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.”

Source location

Response from Downshaw Lodge
Page 4 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop an action plan to improve staff documentation completion.

Verbatim wording from the response

“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.”

Source location

Response from Downshaw Lodge
Page 1 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing provider actions, multi-agency oversight and available documentation processes were considered sufficient to address identified care and recording risks.

Verbatim wording from the response

“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.”

Source location

Response from CQC
Page 3 · response
Published 11 September 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Implement the Single Assessment Framework across sectors, using six evidence categories and ongoing information collection to assess provider quality.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 11 September 2024.
  2. 2

    Publish the findings of the Downshaw Lodge assessment and inspection on the CQC website after completion.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 11 September 2024.
  3. 3

    Analyse residents’ weights, flag significant loss, update care plans and report weight changes monthly.

    Stated by Qualia Care Limited (In AdministrationStated completedThe respondent said that this action was complete when they made their response on 11 September 2024.
  4. 4

    Hold monthly multi-agency meetings to review priorities, stakeholder feedback, resident input, notifications and required escalations.

    Stated by Qualia Care Limited (In AdministrationStated completedThe respondent said that this action was complete when they made their response on 11 September 2024.
  5. 5

    Share the inquest outcome with the staff team.

    Stated by Qualia Care Limited (In AdministrationStated completedThe respondent said that this action was complete when they made their response on 11 September 2024.
  6. 6

    Improve communication between care staff and kitchen teams to provide varied, tailored food for residents at nutritional risk.

    Stated by Qualia Care Limited (In AdministrationStated completedThe respondent said that this action was complete when they made their response on 11 September 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Criminal enforcement was not pursued because the initial assessment found no evidence of registered-provider failure and the enforcement threshold was not met.

    Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement the Single Assessment Framework across sectors, using six evidence categories and ongoing information collection to assess provider quality.

Verbatim wording from the response

“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.”

Source location

Response from CQC
Page 2 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish the findings of the Downshaw Lodge assessment and inspection on the CQC website after completion.

Verbatim wording from the response

“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”

Source location

Response from CQC
Page 5 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Analyse residents’ weights, flag significant loss, update care plans and report weight changes monthly.

Verbatim wording from the response

“Nutritional Monitoring:”

Source location

Response from Downshaw Lodge
Page 2 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Hold monthly multi-agency meetings to review priorities, stakeholder feedback, resident input, notifications and required escalations.

Verbatim wording from the response

“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 Tameside (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.”

Source location

Response from Downshaw Lodge
Page 2 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Share the inquest outcome with the staff team.

Verbatim wording from the response

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

Source location

Response from Downshaw Lodge
Page 4 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Improve communication between care staff and kitchen teams to provide varied, tailored food for residents at nutritional risk.

Verbatim wording from the response

“The Chef at The Home is kept apprised 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.”

Source location

Response from Downshaw Lodge
Page 3 · response
Published 11 September 2024

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Criminal enforcement was not pursued because the initial assessment found no evidence of registered-provider failure and the enforcement threshold was not met.

Verbatim wording from the response

“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.”

Source location

Response from CQC
Page 6 · response
Published 11 September 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026