Leading care home operator HC-One has admitted “unacceptable mistakes” following the conclusion of three coroners’ inquests in the deaths of residents at The Elms care home in Cambridgeshire.

Margaret Canham, George Lowlett and David Poole died within weeks of each other in 2019.

Concluding the inquests last week, coroner Caroline Jones found there had been poor care and issues with record keeping at the home.

Responding last week, HC-One admitted the home, which was one of four care homes closed last year due to staffing problems, should have provided better care for Mrs Canham, Mr Lowlett, and Mr Poole.

A spokesperson said: “We sincerely apologise to the three families involved for our shortcomings, for their experience engaging with our teams, and for the upset that has been caused. We hope this week’s outcomes provide some sense of closure for them.

“The management team in place at The Elms at the time, and the regional management team responsible for overseeing the home, fell far short of everyone’s expectations and standards, and did not live up to our values of transparency and accountability. These individuals are no longer employed by HC-One.

“Our mistakes were acknowledged early on, which is why compensation payments were previously offered to all three families. A full, independent, and public account of the care provided to Mrs Canham, Mr Lowlett, and Mr Poole was always going to take place at these inquests, irrespective of whether the families accepted a compensation payment or not.”

HC-One said The Elms had not used its record keeping system correctly which had led to “unacceptable mistakes” in the care or Mrs Canham, Mr Lowlett and Mr Poole.

The care home provider said it had improve staff training and was currently in the process of moving to a fully digital care record system to prevent such mistakes happening again.

“A lot has changed in the organisation over the past four years, but we know we still have a lot more to do to win back the trust of people in Cambridgeshire,” the spokesperson said.

“We have new management in place, and dedicated regional support, who are working hard to make specific and targeted improvements to our homes within the county. The feedback we have been receiving demonstrates we are moving in the right direction.

“We will review the coroner’s rulings and recommendations from all three cases in detail and will make any requested changes as quickly as possible. Our priority is that every resident living in one of our homes receives the very best care and we are constantly working towards this.”

Rob Assall, CQC’s director of operations for London and East of England, said: “We inspected The Elms Care Home in August 2019, and rated the home as Requires Improvement. From this point onwards we monitored them closely for improvements via further inspections and listening closely to what people were telling us about the quality of care.

“When we re-inspected in June 2022, we found a deterioration in the level of care being provided, so rated the home as Inadequate, and put it into Special Measures. This was to focus their attention on the areas where they rapidly needed to improve and enable them to access improvement help from other organisations in the local health and care system.

“We re-inspected partly to follow up on previous inspections to check on the progress of improvements they were told to make, and due to information provided to us which gave us further concerns about the quality of care being provided.

“When it became clear that HC-One No. 1 Limited wasn’t able to make these improvements, we took steps to cancel the home’s registration to ensure people’s safety. There has been nobody living at The Elms Care Home since August 2022.”

“In terms of further action, CQC identified that we didn’t follow our own internal guidance looking at different lines of enquiries, to see whether the care of Margaret, David and George met the threshold for prosecution. We’re sorry to the families that this has affected, and who may have benefited from the closure this might have brought.  

“Since this time, there was a lessons learnt session for all of the involved staff, and more widely CQC is ensuring all staff are trained in the guidance to prevent this from happening again.”

Speaking to Caring Times, Geanne Poole, the widow of Mr Poole, said: “I am so angry. Our family members died horrendously.

“We were not offered compensation. We were offered a donation to charity or a proportion of our care fees, which we refused.”