Grieving families’ despair at care home inspection gaps
Eleanor Layhe,
Jemma Woodman,South West and
Ella Rule
Trudy PolkinghornCare 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 PolkinghornMr 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 StanilandThe 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”.
