CQC rates Cambridgeshire care home inadequate and places it in special measures

Published: 5 October 2022 Page last updated: 7 October 2022

The Care Quality Commission (CQC) has rated a Whittlesey care home inadequate and placed it in special measures.

CQC inspected the Elms Care Home, on Arnold Lane, due to information received indicating the home may not have made improvements inspectors previously said were required.

The inspection found the service, which is run by HC-One and cares for up to 37 people living with dementia, was not providing standards of care people have a right to expect.

In addition to rating it inadequate overall following the inspection, CQC rated the Elms inadequate for being safe, effective, caring, responsive to people’s needs and well-led. The service was previously rated requires improvement overall.

Due to the poor care inspectors found, CQC placed the service in special measures. This means it is being kept under close monitoring.

Louise Broddle, CQC head of inspection for adult social care, said:

“Standards of care at the Elms were unacceptable. People’s needs and preferences weren’t being met, including during end-of-life care, and they weren’t being treated with dignity or respect.

“We also found people didn’t always receive their medicines as prescribed, and staff didn’t always seek prompt medical advice after making errors. This was worsened because staff didn’t monitor people’s health conditions or make referrals to external professionals when needed.

“A significant factor behind this was the service’s dependency on agency staff. This led to people receiving inconsistent care and the service suffering from a lack of embedded processes to meet people’s needs and keep them safe.

“However, people reported liking the food provided and communal activities. People also told us of kind interactions they received from staff.

“Responsibility for the failings at the Elm’s lies with HC-One as provider of the service. HC-One should have taken all reasonable steps to ensure it could meet people’s needs and ensure their safety. It hadn’t met its responsibilities and consequently subjected its residents to unacceptable standards of care.

“We are keeping the Elms under close review and we will not hesitate to take further action if we are not assured it has made significant improvement. This could include requiring the home’s closure.”

The inspection found:  

  • The service was not well-led. The registered manager and provider of the service, HC-One, failed to carry out their regulatory responsibilities. Quality assurance processes were ineffective, meaning people were exposed to unnecessary risk of harm, and leaders had not always acted as they said they would to improve people’s care
  • People did not always receive their medicines as prescribed. Staff did not always seek prompt medical advice after medicines errors occurred
  • People's needs were not effectively assessed or reviewed, and their care was not always planned in line with best-practice guidance. People's health conditions were not monitored in line with guidance, and necessary referrals were not always made to external healthcare professionals
  • Policies and systems did not support people to have maximum choice and control of their lives, including for decision about their end-of-life care. They also were not always treated with dignity and respect
  • Staff did not always safeguard people from harm. Some potential safeguarding events had not been referred to the local authority, as is required
  • The service was highly reliant on agency workers, resulting in people not receiving timely or consistent care. Staff reported feeling rushed and there was no reliable record of who worked at the home
  • People's fluid and food intake was inconsistently managed. Records for this were not satisfactorily completed, meaning inspectors could not be confident people had enough to drink
  • Staff received an induction when they were first employed at the service. However, they did not always receive an induction when they were promoted. This meant staff did not always know and understand HC-One’s systems or their responsibilities
  • Not all staff had completed relevant training within expected timeframes. However, the registered manager was addressing this
  • Staff did not feel well supported by management.


  • People said they liked the food and they were given choice at mealtimes
  • Some people said they could make decisions about their day-to-day lives, such as when they got up, went to bed and how they spent their day
  • People who could access communal areas told us they had opportunities to pursue interests and join shared activities
  • Some people told us they liked the staff, describing them as good and kind.

Contact information

For enquiries about this press release, email regional.engagement@cqc.org.uk.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.