Grieving families’ despair at care home inspection gaps

BBC research has found that care homes that are inadequate or in need of improvement are often not re-inspected for a year or more.

As of October this year, more than 2,100 care homes in England were rated “requires improvement” by the Care Quality Commission (CQC); but the BBC found that three quarters of these were not re-inspected within a year or more.

One-fifth of the 123 homes rated “inadequate” (the lowest score) were not re-inspected within the same time period.

The BBC’s analysis of CQC data found that a home rated inadequate in 2022 was not re-inspected despite the report highlighting residents were at risk of pressure sores, infection, dehydration and exposure to chemicals.

As a result of the delays, families of residents in low-rated care homes did not always know whether improvements had been made.

The family of a 24-year-old man who died at a care home in Cornwall have called for the homes to be inspected annually.

Lugh Baker died at Rosewood House care home in Launceston, Cornwall, in 2021.

A coroner found deficiencies in his care plan and unexplained gaps in monitoring after his death.

The CQC inspected in 2022 and 2023, telling the home it needed improvements but has not returned for an inspection since then.

Mr Baker’s mother Trudy Polkinghorn and sister Erin Baker said they felt “hopelessness” and were disappointed with the regulator.

The CQC said it “regularly monitors” the service through the information it receives and acts on every recommendation in the forensic report.

CQC divides homes into four categories: outstanding, good, requiring improvement and inadequate.

The institution, which previously re-inspected nursing homes that were evaluated as “improvement required” within a year and homes that were evaluated as “inadequate” within 6 months, got rid of these periods by changing the inspection framework in 2021.

Inspections are now carried out using a more flexible “risk basis”, prioritizing homes deemed the most risky.

Mr Baker had been living at Rosewood House for six months before his death. At the time, it was rated “good” following a 2018 inspection.

Ms. Polkinghorn described her as the “light” and “joy” in their family.

“He wanted to wake up at 7.30 every morning, turn on dance tunes and have everyone dance with him,” he said.

Mr Baker had a rare genetic condition that caused severe learning disabilities, as well as epilepsy and difficulty swallowing.

His care plan called for him to be allowed to eat only certain foods while supervised and sitting upright to prevent choking.

Mr Baker was discovered in his room in April 2021 with an unwrapped, partially eaten chocolate bar next to his bed. The investigation found no signs of drowning.

The coroner’s report criticized the home, saying staff were unaware of her condition and that although residents had to be constantly monitored via CCTV, there were times when this did not happen to her.

Following the inspection in 2018, the house was planned to be re-inspected in two and a half years.

But it was not inspected until four years later, in 2022, a year after Mr Baker’s death, after embankment inspection inspections were cancelled.

CQC was later re-inspected in 2023. In both cases, the home was rated “requires improvement” and was said to be monitored for changes.

No other inspection has been carried out since that date.

Ms Polkinghorn said: “I get so angry when I can get up from a place of utter despair.”

Homes should be inspected annually “at least”, Ms Baker said.

“If there’s a staffing change or something like that, you have to make sure you’re still taking care of people,” he said.

Rosewood House said its “deepest condolences continue to Lugh’s family.”

A spokesman said they had acted on every recommendation in the coroner’s report into Mr Baker’s death, “strengthening monitoring systems and introducing more detailed care plans” and were committed to providing “safe” and “high quality” care.

The CQC said it “regularly monitors” the service through information it receives.

CQC regulates all health and adult social care services in England.

If it judges a care home to be underperforming, it may take enforcement action, including issuing warning notices requiring certain improvements, subjecting a home to special measures and, in serious cases, suspending the registration of a service.

The regulator had previously been warned it needed to improve its performance.

One Independent review by CQC In October 2024, numerous failures were identified, including long gaps between inspections and some services operating without ratings for years.

It found the regulator was experiencing problems due to the new IT system, and concerns were raised that the new audit framework did not provide effective assessments.

There was also a lack of clarity on how ratings were calculated.

The BBC’s analysis of CQC data found that 70% of 204 homes rated “requires improvement” in the South West had not been re-inspected for a year or more.

Eileen Chubb, a former care worker and campaigner who runs the charity Compassion in Care, said she regularly heard from families and staff frustrated by long gaps between inspections.

He said: “We’ve seen the worst care homes, the evil homes, and they haven’t been inspected for two or three years.”

He said whistleblowers told him they had contacted the CQC about “horrific” homes, but by the time the regulator investigated it was “too late” in cases where residents had died.

Some providers said the delays were also unfair to care home owners.

Geoffrey Cox, director of Southern Healthcare, which runs four care homes in the south of England, three of which are rated “outstanding”, said he had a home rated “good” that had not been inspected for seven years.

“It’s too long,” he said, adding that reports going back years had “lost credibility” and eroded the public’s trust in them.

“We want to show that we’re really good at what we do, and we want to be recognized for it,” he said.

A family told the BBC it was a “huge effort” to urge the CQC to “take every precaution” after a loved one died at a home in Norwich.

Karen Staniland’s mother Eileen died in her room at Broadland View care home in Norwich in 2020, when a member of staff who was supposed to be looking after her fell unwitnessed while she slept on duty.

The care plan required that he be checked on hourly at night, that he be given a bed that could be lowered to prevent falls, and that he be provided with a sensor mat that would alert staff if he tried to get up.

A safety report prepared by the local authority after his death found “no aspect” of the care plan was followed.

The carer responsible made false records claiming checks had been carried out and in February 2023 was sentenced to nine months in prison for willful neglect, suspended for two years.

The home was rated “good” in a 2017 inspection, but a former Broadland View employee, who asked to remain anonymous, told the BBC the home did not provide quality care.

“Safety issues were not documented and the equipment and training were not very good,” he said.

“There were these pressure alarm mats, but as soon as you stepped on them they would slide under your feet; they were used as precautions but actually caused falls.”

The former worker said he reported his concerns to the CQC “a number of times” but was “not followed up on”.

The regulator did not inspect the house until three years after Eileen’s death, downgrading it to “requires improvement”.

A coroner’s report in 2023 found the home manager did not acknowledge many of the CQC’s concerns and some promised improvements were not implemented.

Even though two years have passed, the house has still not been re-inspected.

Ms Staniland said the family were “appalled” and “disappointed” at the CQC.

“From our experience, I don’t think it’s regulatory,” he added.

Broadland View care home said it had “learned from the past” and introduced new digital monitoring, stronger night monitoring and regular independent inspections to ensure residents were safe and looked after.

The CQC said it continues to monitor Broadland View and will “continue to work closely with people working on the services and those who use them to understand the issues facing the sector.”

It said it had a clear commitment to increasing the number of evaluations it carries out “to ensure the public has confidence in the quality of care they will receive and to update providers’ ratings to better capture their performance.”