HC-One: The Elms residents 'not safe' at four-inquest care home

Margaret Canham, David Poole and George Lowlett died in 2019

A care home that will close after admitting "shortcomings in care" and failures in leadership has been labelled "not safe" by inspectors.

The Elms in Whittlesey, Cambridgeshire will shut later this month, and the Care Quality Commission (CQC) has found the service to be inadequate.

The inspection came a month after a BBC report into the concerns of relatives of three people who died in 2019.

Provider HC-One apologised for the upset the shortcomings had caused.

The Elms accommodates up to 37 people living with dementia and last week HC-One, one of the UK's largest care providers, confirmed the closure.

In May, the BBC first reported the concerns of relatives about The Elms after their loved ones died in 2019, weeks after a meeting in which worries were raised about "poor care".

Inquests into the deaths of the residents - George Lowlett, Margaret Canham and David Poole - remain ongoing.

HC-One also apologised to the family of Joyce Parrott, who died in April 2020.

Her daughter said no attempt was made to resuscitate her mother after records were mixed up with a person of the same first name.

The care home in Whittlesey, near Peterborough, apologised to Joyce Parrott's family

The council has suspended the referral of new residents to HC-One's care homes in the county because of management concerns.

The month after the BBC's first report, the Care Quality Commission (CQC) began an unannounced inspection of the home and found it to be "inadequate" in all of its measurements.

Inspectors found "people were not safe and were at risk of avoidable harm" and described multiple occasions when people had "not received their medicines as prescribed".

The Elms will close on 23 October

Other findings included:

• Staff had not referred all potential safeguarding events to the local authority

• A failure to "establish systems to ensure people were effectively safeguarded from abuse"

• The provider had failed to learn when things went wrong

• "Widespread and significant shortfalls" in leadership

• No reliable record of the staff that had worked at the home and a reliance upon agency staff, which "resulted in people not receiving consistent care"

Louise Broddle, CQC head of inspection for adult social care, said: "Standards of care at the Elms were unacceptable. People's needs and preferences weren't being met, including during end-of-life care, and they weren't being treated with dignity or respect.

"We also found people didn't always receive their medicines as prescribed and staff didn't always seek prompt medical advice after making errors. This was worsened because staff didn't monitor people's health conditions or make referrals to external professionals when needed.

"A significant factor behind this was the service's dependency on agency staff. This led to people receiving inconsistent care and the service suffering from a lack of embedded processes to meet people's needs and keep them safe.

"However, people reported liking the food provided and communal activities. People also told us of kind interactions they received from staff.

"Responsibility for the failings at the Elms lies with HC-One as provider of the service.

"HC-One should have taken all reasonable steps to ensure it could meet people's needs and ensure their safety. It hadn't met its responsibilities and consequently subjected its residents to unacceptable standards of care."

An inspection report into The Elms was published on Wednesday

The home is due to close on 23 October.

At the time the closure was announced, the chair of Cambridgeshire County Council's adults and health committee, Richard Howitt, said: "I actually think that the investigative journalism that's taken place around HC-One has uncovered some deep faults both within the company and within the system of how these care contracts are awarded."

He told a committee meeting on Wednesday the council would be charging HC-One "in full for all of the additional costs that come to us over arranging alternative suitable care".

Conservative councillor Chris Boden said he was "shocked that HC-One didn't take up the opportunity for the care home to be transferred as a going concern to a third party… and the fact they failed to act positively when the option was open to them I find very, very upsetting".

"I do hope they're not using this as an excuse to try just to sell the site off for capital value and that's what's been at the forefront of their mind, rather than the care of the individuals whom they took on in their establishment and who now face so much uncertainty," he said.

Julie Kerry, HC-One executive director of quality and chief nurse, said: "We are clear that we have not provided the standard of care at The Elms that residents and their loved ones deserve.

"These shortcomings all stem from severe recruitment and retention challenges, which made the day-to-day running of the home very difficult.

"We can only apologise for the upset these shortcomings and the resulting closure decision has caused.

"We are looking closely at what lessons we can take from this experience and where greater oversight could or should take place, but we appreciate this comes too late to change the experience of the residents that have been living at The Elms.

"The immediate priority is to make sure that all residents can quickly and safely move to a new home that meets their care needs."