Grieving families’ despair at care home inspection gaps

Care homes rated as inadequate or requiring improvement often fail to be re-inspected for a year or more, a BBC investigation has found.

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

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

A BBC analysis of CQC data found that one home, which was rated as inadequate in 2022, has not been re-inspected since, despite the report highlighting residents at risk of pressure sores, infections, dehydration and chemical exposure.

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

The family of a 24-year-old man who died in a care home in Cornwall have called for annual inspections of homes.

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

The coroner found deficiencies in his care and gaps in monitoring following his death that remain unexplained.

The CQC carried out inspections in 2022 and 2023, saying the house needed to be improved, but it has not come in for inspections since.

Mr Baker's mother Trudy Polkinghorne and sister Erin Baker said they felt “desperate” and disillusioned with the regulator.

The CQC said it “regularly monitored” the service based on the information received, and the home said it had implemented all recommendations contained in the coroner's report.

The CQC rates homes in four categories: excellent, good, requires improvement and unsatisfactory.

It previously re-inspected care homes rated as “requiring improvement” within a year and those rated “inadequate” within six months, but got rid of those deadlines when it changed its inspection structure in 2021.

Inspections are now conducted based on what they call a more flexible “risk basis,” prioritizing homes they deem the most risky.

Mr Baker lived at Rosewood House for six months before his death. At that time, following an inspection in 2018, it received a “good” rating.

Mrs Polkinghorne described him as the “light” and “joy” of their family.

“He wanted to get up every morning at 07:30, put on dance music and wanted everyone to dance with him,” she said.

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

His care plan called for him to eat certain foods only when supervised and in a sitting position to avoid choking.

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

The coroner's report was critical of the home, saying staff were not familiar with its condition and although residents were supposed to be constantly monitored via CCTV, this was sometimes not the case.

Following an inspection in 2018, the home was required to be re-inspected within two and a half years.

But it was not reviewed until four years later, in 2022, a year after Mr Baker's death, after the required checks were scrapped.

The CQC then re-inspected in 2023. In both cases, the home was rated as “requires improvement” and he was told it would be monitored for changes.

Since then, no further inspections have been carried out.

Ms Polkinghorne said: “When I can pick myself up off the floor, out of a realm of complete despair, I get so angry.”

Ms Baker said homes should be inspected “at a minimum” annually.

“If you have a staff change or anything like that, you need to make sure they're still taking care of people,” she said.

Rosewood House said their “sincere sympathies remain with the Lu family.”

A spokesman said they had implemented all recommendations made 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 “regularly monitored” the service based on the information received.

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

It can take enforcement action if it considers the care home to be underperforming, including issuing warning notices about the need for specific improvements, placing the home under special measures and suspending the service's registration in serious cases.

Previously, the regulator was warned about the need to improve its activities.

An Independently verified by CQC in October 2024, many deficiencies were found, including long gaps between inspections and some services running for years without rating.

The regulator was found to have problems with the new IT system and concerns were raised that the new inspection system was not providing effective assessments.

There was also no clarity on how the ratings were calculated.

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

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

She said: “We've seen the worst care homes – devil's homes – and they don't get inspected for two or three years.”

She said whistleblowers told her they had contacted the CQC about “horrible” homes, but when the regulator carried out an inspection it was “too late” in cases where occupants had died.

Some health care providers said the delays are also unfair to nursing 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 one home rated “good” which had not been inspected for seven years.

“It's too long,” he said, adding that reports from years ago had “lost credibility,” eroding public confidence in them.

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

One family told the BBC it was “an attempt” to get the CQC to “take action” after a loved one died at a home in Norwich.

Karen Staniland's mother Eileen died after falling unexpectedly in her room at Broadland View care home in Norwich in 2020 while the member of staff who was supposed to be looking after her was asleep on duty.

Her care plan stipulated that she should be assessed every hour during the night, that she should be provided with a bed that could be lowered to prevent falls, and that a sensory mat should be provided to alert staff if she attempted to stand up.

A report from the local safeguarding authority after her death found that “no aspect” of her care plan had been followed.

The carer falsified records to suggest checks were carried out and was sentenced to nine months' imprisonment, suspended for two years, for willful neglect in February 2023.

The home was rated “good” in a 2017 inspection, but a former Broadland View employee, who asked not to be named, told the BBC the home was not providing quality care.

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

“There were these mats with pressure alarms, but as soon as you stood on them, they would slide out from under your feet—they were used as protection, but were actually causing falls.”

The former worker said she reported her concerns to the CQC “several times” but no further action was taken.

The regulator only inspected the house three years after Eileen's death, downgrading it to “requires improvement”.

A 2023 coroner's report found that the home manager had not addressed many of the CQC's concerns and that some promised improvements had not been implemented.

Two years have passed and the house has not been re-inspected.

Ms Staniland said the family were left “dismayed” and “disappointed” with the CQC.

“I don’t think it’s a regulatory body based on our experience,” she added.

Broadland View care home said it had “learned from the past” and introduced new digital monitoring, stricter overnight supervision and regular independent reviews to ensure residents were safe and cared for.

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

It said it had made a clear commitment to increase the number of assessments it carried out “to give the public confidence in the quality of care they will receive and to update provider ratings to give a better idea of ​​how they are performing”.