HC-One homes: Whittlesey care home resident 'flinched and begged to leave', inquest hears

A Cambridgeshire care home resident stopped “flinching” and “begging to be taken home” after he moved facilities, an inquest into his death heard.

David Poole was a resident of The Elms Care Home in Whittlesey for around five months before he was relocated to the Ashlynn Grange Care Home in Peterborough in early 2019.

But he “never recovered” from the “neglect and gross failures” he experienced at The Elms – which has since shut down – his widow Jeanne Poole said.

Mr Poole died around a month later, aged 74, having been admitted to Peterborough City Hospital with a suspected chest infection between care home stays.

He had complex health needs in his later years, the inquest heard, including Parkinson’s disease and dementia.

But advice on his care from his specialist nurses was ignored at The Elms, Mrs Poole said, and she was in fact told by a senior nurse at the facility that her husband would never get the level of support he needed because of a lack of time and resources.

Wife told her husband would be evicted if she complained again, inquest hears

Mrs Poole also said that, after repeatedly raising concerns, she was told by the home manager that if she complained again her husband would be evicted.

Among Mr Poole’s specific needs was being monitored every time he ate because he was at a high risk of choking, but Mrs Poole said that this rarely happened and she saw him being left unattended with food.

Asked whether he was always monitored while eating, former Elms manager Katie Coulson said that she “can’t say yes or no; I wasn’t there 24 hours a day”.

She also confirmed that she couldn’t recall whether her staff had received training on how to care for someone with Parkinson’s during Mr Poole’s time at The Elms.

Elms manager apologises to family

Ms Coulson told the inquest that she “can only apologise” that additional care plans weren’t put in place for Mr Poole, which would be expected for someone with his conditions.

But she insisted that The Elms did have sufficient capacity to care for him, a decision she made at the time alongside the home’s clinical lead Rachel Jolly.

Ms Jolly told the inquest that she had actually “raised concerns about Mr Poole’s admission into The Elms”, but agreed that it was ultimately a joint decision.

Ms Jolly was also asked why her notes regarding Mr Poole on 17 February, the day before he was admitted to hospital, read “chest infection” but there is no evidence she contacted a doctor.

Ms Poole said that she asked a doctor to be called on that day, having found her husband unresponsive in bed soaked in faeces with secretions from his nose on his face.

Ms Jolly couldn’t recall this conversation, but said she would have wanted to wait to see whether other medical interventions had an effect first and that she couldn’t see anything in his records that suggest he was unwell enough to warrant a GP visit.

Safeguarding complaint upheld by council

Mrs Poole raised safeguarding concerns about The Elms with Cambridgeshire County Council (CCC) and HC-One, the national care home provider which operated the home.

In early 2019, CCC upheld a complaint regarding “pretty significant” failings, as coroner Caroline Jones put it, including poor record-keeping, poor management of food and drink and failures to adhere to Mr Lowlett’s bowel management needs, which resulted in “distress”.

But after a monitoring visit, CCC rated the home Good.

Head of service and contracted provision Leesa Murray said that the council “absolutely did see improvements” during this period, but continued to monitor the home.

But around the time it was rated Inadequate by the Care Quality Commission (CQC) last year, CCC suspended admissions to all HC-One homes.

The council is due to inform the company whether this embargo will be lifted next week, the inquest heard.

CQC 'missed opportunity' to start potential criminal investigation

Hazel Roberts, deputy director of the CQC for the East of England, told the inquest that the watchdog missed the opportunity to potentially launch a criminal investigation regarding Mr Poole’s care because the time in which it had to do so passed by the time it was raised as a possibility.

But the CQC did take further action after rating the home Inadequate in 2022, ordering it to close and registering a manager, she said.

The individual was not named.

The inquest continues.