Lugh Baker died in 2021 and his mother, Trudy Polkinghorn, said she “was so angry” with the regulator, the CQC
Care homes that are graded as inadequate or requiring improvement are often not being reinspected for a year or more, a BBC investigation has found.
More than 2,100 care homes in England as of October this year were rated as “requires improvement” by the Care Quality Commission (CQC) – but the BBC found three quarters of those had not been reinspected within a year or more.
A fifth of the 123 homes rated as “inadequate” – the lowest rating – have not been reinspected within the same time frame.
BBC analysis of CQC data found one home rated inadequate in 2022 has not been reinspected since, 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 living in poorly rated care homes did not always know whether improvements had been made.
The family of one 24-year-old man who died in a Cornwall care home have called for homes to be inspected annually.
Lugh Baker died at Rosewood House care home in Launceston, Cornwall, in 2021.
A coroner found failings in relation to his care plan and gaps in monitoring after his death, which remains unexplained.
The CQC inspected in 2022 and 2023, telling the home it needed to make improvements, but it has not been back to inspect since.
Mr Baker’s mother, Trudy Polkinghorn, and sister, Erin Baker, said they felt “despair” and were disappointed in the regulator.
The CQC said it had been “regularly monitoring” the service through information it received and the home said it had acted on every recommendation in the coroner’s report.
‘Our light and joy’
The CQC rates homes into four categories – outstanding, good, requires improvement and inadequate.
It previously reinspected care homes rated as “requires improvement” within a year and homes rated as “inadequate” within six months, but got rid of these timeframes when it changed its inspection framework in 2021.
Inspections are now carried out on what it calls a more flexible “risk basis”, prioritising the homes it deems the riskiest.
Mr Baker had been living in Rosewood House for six months before he died. At the time, it was rated “good” following an inspection in 2018.
Ms Polkinghorn described him as a “light” and a “joy” in their family.
“He wanted to get up every morning at 07:30, put the dance tunes on and he wanted everyone to dance with him,” she said.
Trudy Polkinghorn
A coroner’s report criticised the home where Lugh Baker was a resident
Mr Baker had a rare genetic condition which caused severe learning difficulties, as well as epilepsy and difficulty swallowing.
His care plan stipulated he was only allowed to eat certain foods while supervised and sitting up to avoid choking.
Mr Baker was discovered in his room in April 2021 with an unwrapped, partially eaten chocolate bar by his bed. The inquest found no evidence of choking.
A coroner’s report criticised the home, saying staff were unfamiliar with his condition and although residents were supposed to be constantly monitored via CCTV, there were times this did not happen for him.
After its 2018 inspection, the home was scheduled to be reinspected within two-and-a-half years.
But it was not inspected until four years later, in 2022, a year after Mr Baker’s death, following the scrapping of set inspection reviews.
The CQC then reinspected in 2023. On both occasions the home was rated as “requires improvement” and told it would be monitored to make changes.
There has not been another inspection since.
Ms Polkinghorn said: “When I can get up off the floor out of the realms of total despair, I am so angry.”
Ms Baker said homes should be inspected annually “at the very least”.
“If you have a changeover of staff, or anything like that, you need to make sure it’s still caring for the people,” she said.
Rosewood House said their “heartfelt sympathies remained with Lugh’s family”.
A spokesperson 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 remained committed to providing “safe” and “high-quality” care.
The CQC said it had been “regularly monitoring” the service through information it received.
The CQC regulates all health and adult social care services in England.
It can take enforcement action if it judges a care home to be underperforming, including issuing warning notices requiring specific improvements, placing a home into special measures, and suspending the registration of a service in serious cases.
The regulator was previously warned it needed to improve its performance.
An independent review of the CQC in October 2024 found multiple failings, including long gaps between inspections and some services running for years without a rating.
It found the regulator had experienced problems because of a new IT system, and concerns were raised that the new inspection framework was not providing effective assessments.
There was also a lack of clarity around how ratings were calculated.
BBC analysis of CQC data found 70% of the 204 “requires improvement” rated homes in the South West have not been reinspected in 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.
She said: “We’ve seen the worst care homes – diabolical homes – and they’re not inspected for two or three years.”
She said whistleblowers had told her they approached the CQC about “terrible” homes, but when the regulator inspected it was “too late” in cases where residents had died.
Some providers said the delays were unfair to owners of care homes too.
Geoffrey Cox, director of Southern Healthcare which operates four care homes in the south of England, three of which are rated “outstanding”, said he had one “good” rated home that had not had an inspection for seven years.
“It’s far too long,” he said, adding that reports which were years old “lost credibility”, undermining public confidence in them.
“We want to demonstrate that we’re really good at what we do and we want to be recognised for that,” he said.
One family told the BBC it was “such an effort” to encourage the CQC to “take any action at all” after a loved one died at a home in Norwich.
Karen Staniland’s mother Eileen died after an unwitnessed fall in her room at Broadland View care home in Norwich in 2020, while a staff member who was supposed to be looking after her slept on duty.
Her care plan stipulated she must be checked on hourly at night, that she was given a bed which could be lowered to prevent falls and that a sensor mat should be provided to alert staff if she tried to get up.
A local authority safeguarding report after her death found “no aspect” of her care plan had been followed.
The carer responsible had falsified records to suggest checks had been carried out and was sentenced to nine months in prison, suspended for two years, for willful neglect in February 2023.
The home was rated “good” from an inspection in 2017, but a former Broadland View employee, who has asked not to be named, told the BBC the home was not providing quality care.
“Safeguarding issues weren’t being documented, and the equipment and training weren’t very good,” she said.
“There were these pressure alarm mats, but as soon as you stood on them, they would slip from underneath your feet – they were used as preventions, but were actually causing the falls.”
The former worker said she had reported concerns to the CQC on “several occasions” but there was “no follow up”.
Karen Staniland
Karen Staniland said she was disappointed in the CQC
The regulator did not inspect the home until three years after Eileen’s death, downgrading it to “requires improvement”.
A coroner’s report in 2023 found the home’s manager did not accept many of the CQC’s concerns and that several promised improvements had not been implemented.
Two years on, the home has still not been reinspected.
Ms Staniland said the family had been left “dismayed” and “disappointed” in the CQC.
“I don’t think it is a regulator, if our experience is anything to go by,” she added.
Broadland View care home said it had “learnt from the past” and had introduced new digital monitoring, stronger night-time supervision and regular independent audits to ensure residents were safe and cared for.
The CQC said it continued to monitor Broadland View, and it would “continue to work closely with people who work in services and people who use them to understand the issues the sector is facing”.
It said it had a clear commitment to increase the number of assessments it carried out, “in order to give the public confidence in the quality of care they will receive, and to update the ratings of providers to give a better picture of how they are performing”.
The film tells the story of a woman who is grieving the death of her father and becoming obsessed with training a goshawk
An upcoming film hailed as an “unconventional yet moving grief drama” by Variety is set to hit the big screen soon.
Based on Helen Macdonald’s bestselling memoir, the film follows Helen, a woman grappling with the loss of her father, Alisdair Macdonald, portrayed by Brendan Gleeson.
Other stars such as Sam Spruell, Josh Dylan, Denise Gough, Lindsay Duncan, Emma Cunniffe and Arty Froushan also feature in the film.
The much-anticipated movie, H is for Hawk, will be released in cinemas across the UK and Ireland on 23 January 2026, with a new trailer now available for viewing.
Overwhelmed by grief, Helen finds solace in memories of exploring the natural world with her father, reports the Express.
She becomes fixated on the idea of training her own goshawk, introducing us to Mabel.
The synopsis further reveals: “As she labours to tame Mabel, a grieving Helen undergoes an untaming of her own.”
H is for Hawk is a record of a spiritual journey, a story about memory and nature and how it might be possible to reconcile death with life and love.
The drama has already received positive feedback following its premiere at the 52nd Telluride Film Festival in August, boasting a Rotten Tomatoes score of 82%.
Geek Vibes Nation commended the lead cast, stating: “Foy’s emotionally resonant performance is a genuine depiction of grief, while Gleeson anchors the movie with his tender and engaging acting.”
Next Best Picture also chimed in, adding: “Whatever one makes of the title, Claire Foy’s performance alone is reason enough to see it.
“She soars in a role that proves once again why she is among the finest actors working today.”
The Hollywood Reporter concluded: “As an appreciation of birds and our connection to them, it’s engrossing and endearing — a fresher take, certainly, than yet another weepie about dog or cat owners.
“But as an exploration of grief, it’s hindered by a 128-minute run time.”
H is for Hawk will be hitting UK and Ireland cinemas on January 23.
BBC Breakfast presenters Sally Nugent and Jon Kay were left emotional on Tuesday’s show as they spoke to a grieving mum who is still fighting for answers after her son died
08:38, 30 Sep 2025Updated 08:41, 30 Sep 2025
BBC Breakfast presenters Sally Nugent and Jon Kay shared some heartbreaking news on Tuesday’s programme following the tragic death of a young lad.
Kicking off the devastating segment, Jon explained: “Now, from today, social media sites and tech companies will have to preserve data relating to the online activity of a child who has died if requested to do so by a coroner.”
Sally added: “Yes, it’s the latest part of the Online Safety Act to be rolled out, but some parents who’ve lost their children say the measures simply don’t go far enough.”
Following some footage of Jools before his passing, Jon and Sally welcomed Jools’ mother, Ellen, who made a gut-wrenching appeal, according to the Express.
Jon observed, “So it’s an important day. It’s a change. But for you, it’s not a change enough, just explain.”
Ellen responded: “So as of today, there’s something called data preservation notices, which gives the coroner the right to preserve the data. So they’d have to go to Ofcom to preserve online social media data.
“I spoke to two new bereaved parents last night who are in this position. The police are… what happens when an inquest happens is that the inquest is opened and usually suspended and handed back to the police for investigation.
“The problem is the police are then saying, ‘well, we don’t have the power to do that’, then the coroner is not in control, so they can’t use that law. So it seems ridiculous, unless it’s automatic, then the coroners can’t use that law, and then we’re waiting months or potentially years.”
She continued, “The thing that bothers me is that there’s not enough training for police and coroners as well, so the coroner needs to understand what information to ask for. Do all coroners know how TikTok works, or other apps that kids are using, or what information to ask from Snapchat, and so Ofcom needs to help the coroner understand what information to request.”
Ellen went on to reveal that she remains “planning to go to the High Court” in an attempt to “piece together what information was missing” surrounding Jools’ death.
The devastated mum became visibly emotional as she declared, “I think I’m three and a half years down the line. I could get emotional now, but I don’t know why my child’s not here, and I want to try for answers.
“And I think as a parent, I should have the right to try to look at social media, and I get we may be too late now, and this law will help other parents, which is great, but I want to try to understand what happened to my son.”
THE grief-stricken parents of the woman who died with her fiancé of methanol poisoning have revealed they bought the toxic Limoncello that killed them.
Greta Marie Otteson, 33, and Arno Els Quinton, 36, were found dead in their Vietnamese villa on Boxing DayCredit: ViralPress
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Paul and Susan Otteson say they are fighting for justice for Greta and ArnoCredit: Facebook
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The pair passed away less than a month after the pair got engagedCredit: ViralPress
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Tributes poured in for the couple
Cops immediately launched an investigation into the deaths and tests later concluded both died of methanol poisoning, believed to be linked to the tainted limoncello, according to Vietnamese police.
The barman who allegedly made the deadly drink was charged in February and remains detained while investigations continue.
Greta’s parents Paul, 71, and Susan, 70, visited the pair in Vietnam in November 24 – where they had been running a villa and renting rooms out to travellers.
During their stay, they ate at Good Morning Vietnam and enjoyed free shots of Limoncello at the end of their meal.
When they returned home, they decided to order a few bottles of the drink and have them delivered to the couple’s home as a Christmas gift – a decision they would later regret for the rest of their lives.
It was not long before Greta messaged her parents complaining she had the “worst hangover ever” and was suffering from “black spots” in her vision.
The couple reportedly tried to “sleep it off” instead of going to the doctors despite being urged to by pals.
They were found dead three days later in separate rooms of the villa by a cleaner.
The family said the wait for answers has been “unbearable”.
They have received no further update from police nor an apology from the restaurant.
Brit lawyer Simone White, 28, dies in ‘methanol-laced alcohol poisoning’ that left 4 others dead in backpacking hotspot
Paul told the BBC: “It’s about accountability”, adding “we can’t move on”.
Greta and Arno’s ashes are currently stored in two bags in the Ottesons’ home in Rhandirmwyn, Carmarthenshire – one has a pink bunny on top of it, the other a blue bear.
Parents, Paul and Susan, heartbreakingly revealed they can’t face laying them to rest until they have “received justice”.
They said: “Justice for us would be naming the people responsible and prosecuting them.”
TOXIC DRINK
The pair are said to have gone out for dinner on December 24, before returning back to the holiday villa which they own at around 10pm.
Two bottles of limoncello were waiting for them at the reception desk after being delivered earlier in the night by a different restaurant.
The business is said to be popular in the area and a photo of their menu online shows they offer the lemon liqueur at a cheap price.
They advertise a shot as costing 85,000 Vietnamese dong (£2.70) and, according to the menu, it is homemade.
It is unclear how methanol could have been inside the drinks.
The highly toxic industrial chemical is found in antifreeze and windscreen-washer fluid but also appears in some home-brewed or counterfeit alcohol.
HEARTBREAKING TRIBUTES
Greta and Arno Els Quinton passed away less than a month after the pair got engaged.
They had moved to Vietnam together and settled in Hoi An.
The happy couple had taken out a lease out on the gorgeous red-roofed Silverbell Villa where they were later found dead.
It featured a nine-bedroom guesthouse with a swimming pool and sat just ten minutes from Hoi An Ancient Town – a Unesco World Heritage site.
A heartfelt Instagram post on December 3, saw the pair officially announce their engagement to the world.
Days after their bodies were discovered the pair were featured in a touching engagement video posted to YouTube.
A filming studio posted a montage they had made of the pair to celebrate their marriage.
The video shows Greta and Arno, wearing white, dancing, walking hand-in-hand, and expressing the love they shared.
