The estate agent's brochure describes it as a large detached period property set in attractive gardens. What is not mentioned is the catalogue of failures that led to it being on the market. So how did a home run by one of the UK's biggest care providers come to such a chaotic end?

"It was not a very pleasant meeting," says Jeanne Poole of the day she and others expressed their concerns about The Elms care home in Whittlesey, Cambridgeshire.

Mrs Poole's husband David, who had dementia and Parkinson's disease, was being cared for at the 37-bed home, run by HC-One, which calls itself the "Kind Care Company".

Also attending the meeting in February 2019 were some residents, along with family members and HC-One managers. Mrs Poole says she, and relatives of George Lowlett and Margaret Canham, were among the most vocal in raising concerns.

Within two months, all three residents were dead.

Last month, their families sat side by side, supporting one another in a makeshift courtroom at Peterborough Town Hall as coroner Caroline Jones pored over the final days and weeks of their loved ones' lives.

Image source, Steve Hubbard/BBC

In the case of 97-year-old Mrs Canham, a former silver service waitress who took great pride in her five-generation family, the coroner highlighted "suboptimal care".

Her granddaughter Kim Arden told the inquest she felt she had been "lied to" by HC-One since her death.

In the case of Mr Lowlett, 90, an expert witness said the fact the former civil servant had been out of bed for 13 hours the day before he died, despite being on antibiotics for a chest infection, was not "usual practice" and "wasn't evidence of compassionate care".

And the coroner found it "disconcerting to hear" about the discomfort of Mr Poole, 74, after failures to correctly administer his bowel medication, adding that his care was not "safe and effective".

He had been at the home, near Peterborough, since October 2018 and his widow says his decline "was like pushing him off a cliff".

"It was just really shocking to see, and you feel so helpless," she says.

"Nobody was listening and nobody was interested. The home wasn't fit for purpose; it couldn't meet his needs. They failed him so badly and he deserved better."

The families had spent four years seeking answers through medical records and information requests. At the end of the inquest, Ms Jones, while not finding the poor care contributed to the deaths, called their campaign "remarkable".

She acknowledged the "landscape for care in Cambridgeshire has now changed" following their work, as The Elms closed last autumn with HC-One admitting it had "not been able to provide the right standard of care". It is now for sale at £900,000.

Image source, Family photo

But could action have been taken sooner?

In 2019 numerous people were expressing concerns to the Care Quality Commission (CQC), including Mrs Arden, who contacted it nine times.

But the home was not inspected until August 2019 when it was found to be requiring improvement in all areas.

The CQC has since apologised for not inspecting sooner, and to all three families for missing the opportunity to potentially launch a criminal investigation.

Only three months after that inspection, Cambridgeshire County Council's contracts team rated the home as "good."

Shortly afterwards came the Covid-19 pandemic, which curtailed the CQC's inspections.

But by June 2022, following a BBC report about deaths at The Elms and after receiving a letter from local MP, now Health Secretary, Steve Barclay, the CQC went in and rated it inadequate.

Image source, Steve Hubbard/BBC

The BBC has obtained documents under the Freedom of Information Act showing communication between the council and HC-One, throwing light on the home's demise and raising questions over whether bosses learned from deaths.

The inquests of Mr Lowlett, Mrs Canham and Mr Poole highlighted poor record-keeping, revealing that the home had four different sheets on which information could be logged on individuals.

The coroner said this could be "confusing" and that "it was not clear at all times who had recorded what, when", while there were gaps in records prior to Mr Lowlett's death.

After a previous inquest, HC-One apologised to the family of Joyce Parrott, who died in April 2020. No attempt had been made to resuscitate after her records were apparently mixed up with those of someone else called Joyce.

In April 2022, nearly two years to the day after Ms Parrott died, a council officer found the handwriting on care plans was difficult to read, noting "name is not consistent".

They recommended: "Care plans need to be re and Twitter. If you have a story suggestion email eastofenglandnews@bbc.co.uk

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