By Daniel O’Donoghue and William Higgens, BBC North West Investigations Team • Jonathan Fagg, BBC England Data Journalism Unit
BBCThe daughter of an elderly care home resident who suffered 32 falls in only 11 months said she had sent social services “a begging email” to warn her mother “was going to die” unless urgent improvements were made.
“She suffered neglect in every way – it was devastating to see,” said Kylie Gobin, whose mother Winifred Tubb lived at St Luke’s in Runcorn, Cheshire.
Mrs Gobin spoke to the BBC as part of an in-depth investigation which found nearly one in five care homes across England were rated as either “requiring improvement” or “inadequate”.
A spokesman for Halton Borough Council, which operates St Luke’s, said it had “fully investigated” the complaints and “some lessons have been learnt”.
BBC England’s data journalism team analysed Care Quality Commission (CQC) statistics and found the regulator now regards more than 2,500 care homes across England as “requiring improvement”.
The number of “inadequate” homes stands at 194 across England, but this figure is down on both 2022 and 2023.
This could either be due to services improving, care homes closing down, or both.
Common themes in struggling homes included:
- Gaps in staff training
- Mismanagement of medicines
- Accurate records not being kept
- Facilities not meeting safety and cleanliness standards
- Residents’ rights to privacy and dignity not being upheld
- Poor management oversight
Mrs Gobin said her mum – who had worked in the care sector before being diagnosed with dementia in 2010 – moved to St Luke’s in June 2021.
“From the August, she had repeated falls and broke her hip in October 2021,” she said.
“There was an internal inquiry but no lessons were learned until I emailed in April 2022.”
A lower bed, sensory mats and alarms – controlled by a key switch outside Mrs Tubb’s room – were installed so staff could be alerted if she attempted to get out of bed.
On at least two occasions, though, Mrs Gobin says she discovered the alarm had been disabled.
“In November 2022 I visited and found mum on the floor, with the alarms off,” she said.
“I was crying – every emotion you can imagine went through my body. I had to leave the room because I was so angry.
“It would have taken her two or three hours to get into that position because she wasn’t mobile.”
Despite reassurances, just weeks later Mrs Gobin told the BBC she discovered the alarm had again been switched off.
“I was only ever made aware of 12 falls, but in the years since I’ve accessed all my mum’s medical records [and] when I went through them I found she’d actually had 32 falls.
“I was devastated, I just didn’t know as the bruises would have been under her clothes. She must have been in so much pain.”
In the final months of Mrs Tubb’s life, her daughter recalled the moment she summoned up the strength to tell her she was in “terrible pain”.
“At first I thought she was sore from another fall, but I couldn’t see anything wrong.”
Mrs Gobin asked a carer to change her mother’s incontinence pad while she stayed in the room.
“I knew instantly that something was wrong,” she said. “She was covered in blisters – she must have been in horrific pain. I exploded, I was distraught.”
Despite paying hundreds of pounds a week for her mum’s care, Mrs Gobin says she had to go to a pharmacy to buy her some soothing cream.
“People might blame the lack of resources or staff, but this was basic hygiene and care, it’s shocking,” she said.
Mrs Tubb died, aged 78, after contracting Covid in December 2022.
Mrs Gobin, who is calling for an independent review of her mother’s care, told the BBC the CQC initially failed to respond to her concerns.
A spokesman for the regulator said: “In January 2023, we received some information of concern from the relative of someone who had been living at St Luke’s about their care during 2022, which CQC didn’t follow up on until they contacted us again in April 2023, which prompted an inspection of the home in May 2023.
“We apologised to them for not acting as quickly as we should have on the information that they gave us and offered them a meeting with us so they could understand what happened.”
BBC North West spent months speaking with many other concerned families across the region who have or have had relatives in care homes.
Despite paying up to £1,000 a week for care, some families shared harrowing stories of how their loved ones were allegedly neglected.
They included claims:
- Bones were broken in multiple falls
- Residents were not washed and were left in unsanitary conditions
- One patient had a urine bottle left on his breakfast table, alongside food
- Vulnerable people were not fed properly
Down the corridor from Mrs Gobin’s mother at St Luke’s, former council worker Raymond Thomas, then 65, was beginning a five-month stay in the home.
He had been diagnosed, aged 60, with dementia in 2017 and had been cared for at home by his wife Paula until November 2022, when she needed additional support.
The Thomas family found St Luke’s after conducting online research, noting the home’s “good” rating on the CQC website.
“It was mayhem from the first week,” Mrs Thomas said. “He was only in there two days and he fell out of bed.
“There was no sensory mat on the floor, they told me he wouldn’t have been on the ground for more than two hours, but we don’t know. This was November, it was cold.”
Mrs Thomas added: “He had more falls after that in different areas of the home, I didn’t want to ever leave him.”
On several occasions she said her “quiet family man” husband of 47 years had not been washed or changed.
“After five months in there he was rushed to hospital with sepsis. While in the hospital we noticed his teeth were black and his hair was greasy.
“This was a man who was always spotlessly clean.”
The father-of-two, who also had three grandchildren, remained in hospital for a month until his family found him another care home.
He died in January 2024.
The Thomases, along with four other families, are taking civil legal action against St Luke’s, alleging neglect.
The families are all represented by the same law firm.
“Unfortunately, this is not the first home where we have represented multiple clients,” Leigh Day partner Emma Jones said.
“Often people will say to me that they have come to lawyers because they have complained to the home and then the ombudsman and the CQC but they haven’t received answers.
“Therefore, they are forced to litigate to try to get the answers they seek so desperately.”
Ms Jones told the BBC that litigation often only starts after a resident has died because “family members are afraid of the consequences of complaining”.
“The CQC can state a service requires improvement or is inadequate but how often do we see further action being taken? I have not seen this in any of my cases,” she said.
Halton Borough Council said it consistently aimed to “provide good person-centred care”.
A spokesperson said it was “regretful that families have felt the need to complain about the care and support of their family members.
“All concerns have been fully investigated by our adult safeguarding team, and some lessons have been learnt following these complaints.
“We have provided details to family members on the findings of our investigations.
“We are unable to provide further detail due to the ongoing legal case.”
The CQC said it was “monitoring the home closely while they are making improvements” and “will return to inspect to check improvements have been made”.
The CQC said it encouraged feedback about care services from the public.
‘National shame’
Helen Wildbore, director of the Care Rights UK charity, said “time and time again” she and her team had spoken to families and care residents who had had similar experiences.
“They tell us they feel like they are trapped in a broken system, it should be a sense of national shame that this is happening in our care services in this country,” she said.
“The CQC should be there to make sure that standards are being met and should be there to represent the voice of people who are using care services.
“We desperately need to see a change.”
The CQC said its “main priority” was to “ensure the health and wellbeing of people” using care services.
“This includes listening to what they – and their loved ones – tell us about services, to help us decide when and where to inspect, ensuring we have the full picture,” a spokesman said.
The CQC does not have any legal powers to investigate individual incidents, however.
The BBC also spoke with care home managers and staff who said they were under increasing pressure.
“We’re very short of staff,” Mike Padgham, who runs the Independent Care Group which advocates for care homes, said.
“Across England, there’s 152,000 vacancies,” he said. “By 2035, we need 440,000 extra staff in social care.”
A carer from a North West home, who wished to remain anonymous, said: “People just don’t want to stay any more – more so now because you’re not appreciated.”
The carer told us they did not believe the CQC was “doing enough spot checks”.
“Nine times out of 10 there is stuff that goes under the radar,” she said.
A Lancashire-based manager, who runs a “good” rated home, was also critical of the CQC.
The manager, who also wished to remain anonymous, said: “Coming out to do an inspection is a ludicrous idea because one day everything can be great, another day it’ll be a disaster.
“We should have a close relationship with our inspectors and we should not fear them to the extent that we do.”
The CQC, which is currently being reviewed by the government, said it “worked hard to ensure we minimise our impact on providers while doing everything within our power to make sure people receive good quality, safe care”.
A spokesman added: “We are reviewing and enhancing the training we give to CQC staff to protect the welfare of providers following inspection.”
Remembering her late mum, Mrs Gobin said: “I can’t change the past, but we can shape the future.
“People deserve the right to live a dignified life when they go into a care home. We’ve got be open and honest and learn from all of this.”