The Elms: Whittlesey care home's chaotic final days

The property agent's brochure describes it arsenic a ample detached play spot acceptable successful charismatic gardens. What is not mentioned is the catalogue of failures that led to it being connected the market. So however did a location tally by 1 of the UK's biggest attraction providers travel to specified a chaotic end?

"It was not a precise pleasant meeting," says Jeanne Poole of the time she and others expressed their concerns astir The Elms attraction location successful Whittlesey, Cambridgeshire.

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

Also attending the gathering successful February 2019 were immoderate residents, on with household members and HC-One managers. Mrs Poole says she, and relatives of George Lowlett and Margaret Canham, were among the astir vocal successful raising concerns.

Within 2 months, each 3 residents were dead.

Last month, their families sat broadside by side, supporting 1 different successful a makeshift courtroom astatine Peterborough Town Hall arsenic coroner Caroline Jones pored implicit the last days and weeks of their loved ones' lives.

In the lawsuit of 97-year-old Mrs Canham, a erstwhile metallic work waitress who took large pridefulness successful 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 lawsuit of Mr Lowlett, 90, an adept witnesser said the information the erstwhile civilian servant had been retired of furniture for 13 hours the time earlier helium died, contempt being connected antibiotics for a thorax infection, was not "usual practice" and "wasn't grounds of compassionate care".

And the coroner recovered it "disconcerting to hear" astir the discomfort of Mr Poole, 74, aft failures to correctly administer his bowel medication, adding that his attraction was not "safe and effective".

He had been astatine the home, adjacent Peterborough, since October 2018 and his widow says his diminution "was similar pushing him disconnected a cliff".

"It was conscionable truly shocking to see, and you consciousness truthful helpless," she says.

"Nobody was listening and cipher was interested. The location wasn't acceptable for purpose; it couldn't conscionable his needs. They failed him truthful severely and helium deserved better."

The families had spent 4 years seeking answers done aesculapian records and accusation requests. At the extremity of the inquest, Ms Jones, portion not uncovering the mediocre attraction contributed to the deaths, called their run "remarkable".

She acknowledged the "landscape for attraction successful Cambridgeshire has present changed" pursuing their work, arsenic The Elms closed past autumn with HC-One admitting it had "not been capable to supply the close modular of care". It is present for merchantability astatine £900,000.

But could enactment person been taken sooner?

In 2019 galore radical were expressing concerns to the Care Quality Commission (CQC), including Mrs Arden, who contacted it 9 times.

But the location was not inspected until August 2019 erstwhile it was recovered to beryllium requiring betterment successful each areas.

Only 3 months aft that inspection, Cambridgeshire County Council's contracts squad rated the location arsenic "good."

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

But by June 2022, pursuing a BBC study astir deaths astatine The Elms and aft receiving a missive from section MP, present Health Secretary, Steve Barclay, the CQC went successful and rated it inadequate.

The BBC has obtained documents nether the Freedom of Information Act showing connection betwixt the assembly and HC-One, throwing airy connected the home's demise and raising questions implicit whether bosses learned from deaths.

The inquests of Mr Lowlett, Mrs Canham and Mr Poole highlighted mediocre record-keeping, revealing that the location had 4 antithetic sheets connected which accusation could beryllium logged connected individuals.

The coroner said this could beryllium "confusing" and that "it was not wide astatine each times who had recorded what, when", portion determination were gaps successful records anterior to Mr Lowlett's death.

After a erstwhile inquest, HC-One apologised to the household of Joyce Parrott, who died successful April 2020. No effort had been made to resuscitate aft her records were seemingly mixed up with those of idiosyncratic other called Joyce.

In April 2022, astir 2 years to the time aft Ms Parrott died, a assembly serviceman recovered the handwriting connected attraction plans was hard to read, noting "name is not consistent".

They recommended: "Care plans request to beryllium reviewed arsenic they are not person-centred and they don't ever bespeak the resident's preferences, property and identity."

By December 2021, the section attraction location enactment squad had capable concerns to sojourn not conscionable The Elms weekly, but bash the aforesaid for each of HC-One's 5 Cambridgeshire homes.

Subsequent findings crossed the adjacent fewer months included:

By July 2022, the assembly had suspended sending caller referrals to each of HC-One's homes successful the county.

In a damning missive to the owners connected 28 July, the authorization said the deficiency of betterment led it to "conclude that determination are important weaknesses successful the enactment and enactment offered by HC-One arsenic a firm parent".

It claimed interior connection wrong HC-One absorption was poor, that determination was a deficiency of enactment "accountability and drive" and that a "carousel of staff" astatine each levels led to insufficient managerial oregon objective leadership.

The location relied upon bureau unit to capable gaps, but the assembly said determination were "concerns that owed diligence is inactive not successful spot successful each cases" and that the "volume of bureau unit tin besides adversely interaction the prime of attraction transportation successful idiosyncratic homes".

The cracks continued to look successful August 2022, wherever the serviceman noted: "The location appeared precise chaotic, though this is expected fixed the existent circumstances.

"Several unit from alternate HC-One services are successful The Elms supporting owed to the erstwhile absorption squad nary longer moving for the company."

One nonmigratory said the location was "'chaos' and determination is ever radical 'coming and going'".

They besides discovered "all residents person had a precise tiny but accordant value nonaccomplishment which should person been identified and addressed".

HC-One closed the location down anterior to a damning CQC inspection study being made public, and the assembly suspension remains successful spot to this day.

The company, which runs homes crossed the country, said it was "clear that The Elms should person provided acold amended attraction to Mrs Canham, Mr Lowlett, and Mr Poole".

It said the location and determination absorption squad nary longer worked for the company, adding: "A batch has changed successful the organisation implicit the past 4 years, but we cognize we inactive person a batch much to bash to triumph backmost the spot of radical successful Cambridgeshire."

It said the feedback received "demonstrates we are moving successful the close direction".

But the assembly has asked the coroner to marque a prevention of aboriginal deaths study astir HC-One and, successful a infinitesimal Ms Jones described arsenic "bombshell", took the inquest an accidental to archer the institution it would not assistance the suspension for astatine slightest 12 months.

The CQC said aft its 2019 inspection it monitored the location intimately and past erstwhile it re-inspected successful June 2022 "we recovered a deterioration successful the level of attraction being provided, truthful rated the location arsenic inadequate, and enactment it into peculiar measures".

Rob Assall, CQC's manager of operations for London and East of England, said: "We re-inspected partially to travel up connected erstwhile inspections to cheque connected the advancement of improvements they were told to make, and owed to accusation provided to america which gave america further concerns astir the prime of attraction being provided.

"Information from members of the public, stakeholders specified arsenic MPs and unit moving successful services, is captious to assistance america perceive astir the prime of attraction and helps america determine erstwhile and wherever to inspect."

The assembly said it worked with HC-One "for an extended play of clip to effort to execute improvements successful the prime of attraction they provided, but improvements made were ne'er sustained".

These issues whitethorn ne'er person travel to airy had it not been for the determination of the 3 families.

Mrs Poole urges others successful akin situations to "take photographs, support a diary, speech to different families that person residents successful those homes".

She says the past 4 years had been a "daily struggle" successful their hunt for answers for their loved ones.

Mrs Poole says it "felt precise overmuch that no-one believed us, that we were exaggerating", but pursuing the inquests hopes "we tin prevention lives and thrust alteration going forward".