Francis Leech

Dear Coroner, I write in relation to the Regulation 28 report which was issued in connection with the Inquest into the death of Francis Leech, who was a resident of Bowood Court Care Home (“the Home”). The Inquest into Mr Leech’s death was held at Worcestershire Coroner’s Court on 26 May to 2 June 2026. Prior to and during the course of the Inquest the Home provided evidence to assist your inquiry into the care arrangements in place and the reflection which has taken place to strengthen the Home’s systems and procedures following the incident involving Mr Leech and another resident on 25 October 2023. A Regulation 28 Report was, however, issued to myself as Managing Director of Adept Care Home’s Limited on 2 June 2026 which raised concerns regarding the following:
1. Staff did not understand the importance of updating care plans and behavioural support plans;
2. Management of the Home had not instigated a system of checking and ensuring those plans were updated; and
3. The internal investigation carried out after the incident did not recognise deficiencies in those plans or put in place measures to ensure they were not repeated. I can confirm that a copy of the Regulation 28 Report has been disseminated to the wider management team for their consideration and that the below reflects the company’s response. Resident Care Plans and Behavioural Support Plans The Home’s management and senior care team are principally responsible for the creation, review and amendment of resident care plans and Behavioural Support Plans. Following creation, resident care plans and Behavioural Support Plans are reviewed and updated on a monthly basis or as required in response to changing resident care needs. Support from an individual with dementia expertise is also available to the Home to draw upon as required. The importance of reviewing and updating resident care plans and Behavioural Support Plans is regularly communicated to responsible staff from the point of joining the Home and forms part of the training delivered. During evidence it was explained that monthly

audits of care plans and Behavioural Support Plans by the Care Manager have been introduced. Following the conclusion of the Inquest into Mr Leech’s death, a further instruction was issued to the Home management and senior care team reaffirming the expectations in relation to the review and amendment of Behaviour Support Plans and the introduction of supporting risk assessments in reflection of lessons learnt. We would also note that a new Home Manager and Care Manager are now in place with oversight of the Home following the incident involving Mr Leech. In respect of incident investigations, the Home acknowledges that the investigation into the incident involving Mr Leech did not identify gaps within the care plans and Behavioural Support Plans in place. Having reflected upon this, steps have been taken to require that an individual with dementia expertise assist in completing internal investigations where an individual involved is considered to be living with dementia. By introducing this additional expertise to the investigation process, we believe that this will allow for more in depth scrutiny of care arrangements and behaviours, and for appropriate actions to be taken. In addition, as advised during the Inquest, practices are now in place to ensure that spot checks are conducted on a twice weekly basis of incident and accident report completion and feedback is provided to the Home as required. This is in addition to their regular in person visits to the Home. Accordingly, the Home has taken steps to review the arrangements in place for the oversight of care plans and Behavioural Support plans which are now considered to be appropriate in all the circumstances. I hope that this response is of assistance to the Coroner in confirming the care arrangements currently in place. I would like to conclude by expressing my sincere condolences to Mr Leech’s family for their loss. Signed Managing Director