The Elms: Whittlesey care home's chaotic final days

The estate agent's brochure describes it as a large detached period property set in attractive gardens. What is not mentioned is the catalogue of failures that led to it being on the market. So how did a home run by one of the UK's biggest care providers come to such a chaotic end?

"It was not a very pleasant meeting," says Jeanne Poole of the day she and others expressed their concerns about The Elms care home in Whittlesey, Cambridgeshire.

Mrs Poole's husband David, who had dementia and Parkinson's disease, was being cared for at the 37-bed home, run by HC-One, which calls itself the "Kind Care Company".

Also attending the meeting in February 2019 were some residents, along with family members and HC-One managers. Mrs Poole says she, and relatives of George Lowlett and Margaret Canham, were among the most vocal in raising concerns.

Within two months, all three residents were dead.

Last month, their families sat side by side, supporting one another in a makeshift courtroom at Peterborough Town Hall as coroner Caroline Jones pored over the final days and weeks of their loved ones' lives.

In the case of 97-year-old Mrs Canham, a former silver service waitress who took great pride in her five-generation family, the coroner highlighted "suboptimal care".

Her granddaughter Kim Arden told the inquest she felt she had been "lied to" by HC-One since her death.

In the case of Mr Lowlett, 90, an expert witness said the fact the former civil servant had been out of bed for 13 hours the day before he died, despite being on antibiotics for a chest infection, was not "usual practice" and "wasn't evidence of compassionate care".

And the coroner found it "disconcerting to hear" about the discomfort of Mr Poole, 74, after failures to correctly administer his bowel medication, adding that his care was not "safe and effective".

He had been at the home, near Peterborough, since October 2018 and his widow says his decline "was like pushing him off a cliff".

"It was just really shocking to see, and you feel so helpless," she says.

"Nobody was listening and nobody was interested. The home wasn't fit for purpose; it couldn't meet his needs. They failed him so badly and he deserved better."

The families had spent four years seeking answers through medical records and information requests. At the end of the inquest, Ms Jones, while not finding the poor care contributed to the deaths, called their campaign "remarkable".

She acknowledged the "landscape for care in Cambridgeshire has now changed" following their work, as The Elms closed last autumn with HC-One admitting it had "not been able to provide the right standard of care". It is now for sale at £900,000.

But could action have been taken sooner?

In 2019 numerous people were expressing concerns to the Care Quality Commission (CQC), including Mrs Arden, who contacted it nine times.

But the home was not inspected until August 2019 when it was found to be requiring improvement in all areas.

The CQC has since apologised for not inspecting sooner, and to all three families for missing the opportunity to potentially launch a criminal investigation.

Only three months after that inspection, Cambridgeshire County Council's contracts team rated the home as "good."

Shortly afterwards came the Covid-19 pandemic, which curtailed the CQC's inspections.

But by June 2022, following a BBC report about deaths at The Elms and after receiving a letter from local MP, now Health Secretary, Steve Barclay, the CQC went in and rated it inadequate.

The BBC has obtained documents under the Freedom of Information Act showing communication between the council and HC-One, throwing light on the home's demise and raising questions over whether bosses learned from deaths.

The inquests of Mr Lowlett, Mrs Canham and Mr Poole highlighted poor record-keeping, revealing that the home had four different sheets on which information could be logged on individuals.

The coroner said this could be "confusing" and that "it was not clear at all times who had recorded what, when", while there were gaps in records prior to Mr Lowlett's death.

After a previous inquest, HC-One apologised to the family of Joyce Parrott, who died in April 2020. No attempt had been made to resuscitate after her records were apparently mixed up with those of someone else called Joyce.

In April 2022, nearly two years to the day after Ms Parrott died, a council officer found the handwriting on care plans was difficult to read, noting "name is not consistent".

They recommended: "Care plans need to be reviewed as they are not person-centred and they don't always reflect the resident's preferences, personality and identity."

By December 2021, the local care home support team had enough concerns to visit not just The Elms weekly, but do the same for each of HC-One's five Cambridgeshire homes.

Subsequent findings across the next few months included:

By July 2022, the council had suspended sending new referrals to all of HC-One's homes in the county.

In a damning letter to the owners on 28 July, the authority said the lack of improvement led it to "conclude that there are significant weaknesses in the leadership and support offered by HC-One as a corporate parent".

It claimed internal communication within HC-One management was poor, that there was a lack of leadership "accountability and drive" and that a "carousel of staff" at all levels led to insufficient managerial or clinical leadership.

The home relied upon agency staff to fill gaps, but the council said there were "concerns that due diligence is still not in place in all cases" and that the "volume of agency staff can also adversely impact the quality of care delivery in individual homes".

The cracks continued to appear in August 2022, where the officer noted: "The home appeared very chaotic, although this is expected given the current circumstances.

"Several staff from alternative HC-One services are in The Elms supporting due to the previous management team no longer working for the company."

One resident said the home was "'chaos' and there is always people 'coming and going'".

They also discovered "all residents have had a very small but consistent weight loss which should have been identified and addressed".

HC-One closed the home down prior to a damning CQC inspection report being made public, and the council suspension remains in place to this day.

The company, which runs homes across the country, said it was "clear that The Elms should have provided far better care to Mrs Canham, Mr Lowlett, and Mr Poole".

It said the home and regional management team no longer worked for the company, adding: "A lot has changed in the organisation over the past four years, but we know we still have a lot more to do to win back the trust of people in Cambridgeshire."

It said the feedback received "demonstrates we are moving in the right direction".

But the council has asked the coroner to make a prevention of future deaths report about HC-One and, in a moment Ms Jones described as "bombshell", took the inquest an opportunity to tell the company it would not lift the suspension for at least 12 months.

The CQC said after its 2019 inspection it monitored the home closely and then when it re-inspected in June 2022 "we found a deterioration in the level of care being provided, so rated the home as inadequate, and put it into special measures".

Rob Assall, CQC's director of operations for London and East of England, said: "We re-inspected partly to follow up on previous inspections to check on the progress of improvements they were told to make, and due to information provided to us which gave us further concerns about the quality of care being provided.

"Information from members of the public, stakeholders such as MPs and staff working in services, is vital to help us hear about the quality of care and helps us decide when and where to inspect."

The council said it worked with HC-One "for an extended period of time to try to achieve improvements in the quality of care they provided, but improvements made were never sustained".

These issues may never have come to light had it not been for the determination of the three families.

Mrs Poole urges others in similar situations to "take photographs, keep a diary, talk to other families that have residents in those homes".

She says the past four years had been a "daily struggle" in their hunt for answers for their loved ones.

Mrs Poole says it "felt very much that no-one believed us, that we were exaggerating", but following the inquests hopes "we can save lives and drive change going forward".

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