Bernard Lyon

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: 03000 616161 
Fax: 03000 616171 

30 May 2025 

Our Reference: 
Your reference: 

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, 
December 2023. 

 who was registered on 14 

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. 

1 

A1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 
the  provider  performs  against 
corroborate  evidence  and  reassurance  of  how 
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 

2 

A2 
 
 
 
  
 
 
 
 
 
 
 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. 

3 

A3 
 
 
 
 
 
 
 
 
 
 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.  

’s statement from the evidence bundle, that he said, “The council and 

I note in 
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 

4 

A4 
 
 
 
 
 
 
 
 
 
 
 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 

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A5 
 
 
 
 
 
 
 
 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 

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A6 
 
 
 
 
 
 
 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.    

Yours sincerely, 

Deputy Director of Operations  

Network North, CQC  

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A7

From 

Minister of State for Care   

39 Victoria Street   
London   
SW1H 0EU  

04 June 2025  

Our ref: 

HM Senior Coroner Alison Mutch  
Coroner's Court  
1 Mount Tabor Street  
Stockport  
SK1 3AG  

By email: 

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  

A9  
   
  
  
   
  
  
  
  
  
        
  
      
   
   
   
  
   
 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.   

A10  
  
  
   
  
  
  
 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.    

Yours sincerely,  

MINISTER OF STATE FOR CARE  

A14

BY EMAIL ONLY 
Ms Alison Mutch OBE 
Coroner 
HM Coroner’s Office 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

ADULTS 
DIRECTORATE 

Head of Service 

Tameside One 
Market Place 
Ashton-under-Lyne 
Tameside 
OL6 6BH 
Call Centre            0161 342 8355 

www.tameside.gov.uk  

e-mail:  
Doc Ref 
Ask for 
Direct Line 
Date                      3 June 2025 

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. 

Yours sincerely 

Head of Commissioning 
Adult Services 

A8