Ronald Perry

FAO:  Ms Alison Mutch – Senior Coroner

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

Re:- Ronald Perry (14 Nov 25)

CORONER’S CONCERNS (The Lakes response in black after each point)

During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths could occur unless
action is taken. In the circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows. –

1. During the course of the inquest it was difficult to be clear at times as to
what care had been delivered or what steps had been taken because the
documentation relating to care and risk was poor.

The Lakes Care Centre accepts that the information shared during the hearing fell
short of what should be available. The Lakes has faced challenging times since it
was bought out of financial receivership in September 2023. We have had a series of
Home Managers who have not been able to effect the positive change we needed to
see. However, in late December 2023 we appointed a new, experienced manager
who has been working very closely with myself and Tameside Council’s Quality
Improvement Team.

We have seen all aspects of the care we provide improve over the period from early
2025 to now. This has resulted in Tameside Council changing the status of our home
from MAC 2 down to MAC 1 (which is the lowest level of ‘oversight’). This is as a
direct result of the improvements we have made in areas such as record keeping,
responding to emergencies and also training and development of our employees to
be better equipped.

We have undertaken a period of internal Induction training of all Senior Carers (7
weeks in total) and this followed a recognised programme or Senior Carers in
residential /nursing homes.

In addition to this we have undertaken a review of our Digital Care Record system
and with Tameside’s support began using it much more effectively in terms of
auditing and governance. This has led to improvements in protocols such as fall
management.  In addition, we have improved in the following areas:

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 a)  Pre/New Admission Protocol – we adopted a new and thorough approach

which enables our team to ensure we have all information to create a full and
complete Care Plan from Day 1 and ensure all accompanying Risk
Assessments are in place to support the Care Plans.

b)  Care Plan – Reviews These are now allocated to certain key individuals (All
Seniors Carers and Leaders) to ensure all are checked at least monthly and
nay updates added. If changes occur in between reviews then the Care Plan
and Riska assessments are updated accordingly and communicated with the
teams.

c)  Whole Team Skill Review – The Leadership Team at The Lakes assessed its
employees and whether or not they were fit for the role they were employed in
and if they were in the right role within the Lakes. This resulted in a number of
key people (who led teams and influenced practice) leaving our organisation.
We then appointed new key people to help us move forward with our agenda
of positive outcomes and impact for all people who use and visit our service.
To date this is going well and we are now seeing big improvements in routine
and regular practice improving, form better shift handovers, record keeping,
referring on to specialist services and all resulting in a reduction in complaints,
concerns and leading to more compliments about how we respond to issues
and deliver support to our lovely residents.

d)   Auditing/Governance – the Lakes now has in place clear and robust process
for self-auditing and leadership governance. This has resulted in matters
being identified earlier and solutions being found straight away. This is being
supported by an effective in-house HR function. They address matters such
as poor attendance, performance matter s and support of issues such as
flexible working time requests. In essence everyone now understands what is
expected of them and how to identify when they are ‘doing things right’.

e)  Involving Residents and their families/significant others in the Care Needs /

Plan creation form day one.

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 2. The falls risk assessment documentation was incomplete and did not
appear to have been updated after falls had occurred.

The Lakes Care Centre now has clear guidelines and protocols to follow in all falls –
whether serious or apparently innocuous. The guidance now direct people to report
on every occasion (using Digital health – during operating hours, NHS 11 support or
NHS 999 support).

These occasions are recorded on our digital care record system for protection of
data and ability to share the incidents more readily and easily.  When any falls
occurs in between monthly reviews then this triggers a re-assessment and review of
the residents needs to see if anything has changed and how this will impact their
Risk Assessment and our approach to supporting their needs.

This is possible as all Falls Risk Assessments and Care Plans are written upon
admission and reviewed monthly. We are also beginning to analyse the falls matrix
within our Digital Care Record and identify various indicators such as time of falls,
location, type of fall (unwitnessed/witnessed/fall form chair/bed/ whilst walking etc)
with a view to seeing if we can improve our offer to these people or if there is an
environmental issue we need to review and improve to minimise the risks of falls.

This is all against a new trend for people being referred / admitted from hospital with
higher falls risk assessment under the banner of Residential Care.

3. The falls policy regarding the need to seek medical advice where a
resident on anticoagulation had a fall that had been unwitnessed did not
seem to be widely understood by staff or adhered to on all occasions.

The Lakes Care centre agrees that some people charged with supporting our
residents, did not fully understand the policy and protocols that re in place when
people experience falls at The Lakes Care Centre.

Our approach to assessing our employees did focus on such matters. This has led to
the re-training of all Senior Carers (who take the lead on any falls management) and
ensuing people who are responsible both understand and in act the falls protocol
fully and those who cannot meet this new standard approach are no longer in
positions of authority or influence.

Our Senior Care Team now understand the need to seek support for all falls and
how the data we capture at the time is vita for all health professionals in giving the
best clinical support but also how we at The Lakes Care Centre can use the data to
improve our services and ultimately reduce the risk and incidence of falls at The
Lakes Care Centre.

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 Finally, after all this soul searching and reviewing we have now implemented a Falls
Champion at The Lakes. The Champion is a Senior Person and will undertake in
collaboration with Nottingham University, a 5-week training and awareness training
programme. This will equip them with the knowledge and skills to be able to effect
positive responses to all falls and falls risk management. They will be responsible to
coaching, training and assessing our teams for their approach to this subject.

The Lakes Care Centre recognises Falls Management as one of our priorities at the
moment. We are sure the net effect of all the actions highlighted above will improve
the outcomes for all residents at The Lakes Care Centre but in particular those at
higher risk of falls.

Written by:

 – Director of Operations

 – Registered Manager

Date: 11th December 2025

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