- Care home
Bearwardcote Hall Residential Home
Assessment report published 14 January 2026
Contents
Ratings
Our view of the service
Date of assessment: 14–15 and 21 October 2025
Service type: Residential care home for adults over 65 years
Bearwardcote Hall Care Home is a residential care home providing personal care to people aged 65 and over. At the time of the inspection 23 people were using the service. The service can support up to 39 people.
During this inspection, we looked at all the quality statements in the key questions of safe, effective, caring, responsive and well-led. We found five breaches of the legal regulations in relation to safe care and treatment, consent, safeguarding, staffing and governance.
Whilst some safe practices were in place, people were at risk of harm and several regulations were not met due to the provider’s failure to consistently identify, manage, and mitigate risk. Incident reporting was incomplete and did not capture behaviours of distress or allegations of abuse. Complaints and safeguarding concerns were not always escalated or investigated, leaving people vulnerable. Environmental risks were poorly assessed and addressed, with issues such as unsafe staircases, scalding hazards, damp, and mould present throughout the premises. Infection prevention and control measures required significant improvement, including the lack of suitable facilities for cleaning and disposal of continence aids, inconsistent use of PPE, and poor hygiene standards in communal and kitchen areas. Medicines were not always managed safely, with limited auditing, insufficient oversight, and a lack of staff competency in monitoring.
There were widespread shortfalls in care and support. People were not consistently involved in planning or reviewing their care, and their needs and preferences were not always considered or documented. Mental capacity assessments, best interest decisions and Deprivation of Liberty Safeguards authorisations were not always completed when required.
The service was not consistently caring because people’s dignity, privacy, and independence were not always maintained, and communication with people and their families was inconsistent. Activities and meaningful engagement were limited, particularly for those living with dementia, contributing to social isolation.
Governance and leadership were ineffective. Systems for monitoring safety, quality, and compliance were not robust, and the registered manager had limited oversight of staff practice, training, and environmental risk management. Staff reported low morale, high workloads, and insufficient support, with ongoing cultural tensions and limited team development.
The provider was in breach of five regulations relating to safe care and treatment, safeguarding, consent, staffing, and governance. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded.
This service is being placed into special measures. The purpose of special measures is to ensure that services rated as inadequate make significant improvements. This framework allows CQC to use enforcement powers where necessary and sets a clear timeframe for the provider to improve the quality of care delivered.
People's experience of this service
Whilst most people and their relatives expressed that they were happy with aspects of their care, our assessment found several elements of the service did not meet expected standards.
People told us they generally felt safe and described staff as caring and supportive. However, some expressed feeling unsafe due to the behaviour of other people who used the service, including incidents of agitation, banging on doors, and attempts to enter bedrooms. This meant that risks in communal areas were not always effectively managed to protect people’s wellbeing.
People and their relatives reported limited involvement in their care planning and did not always know what their care plans contained. Similarly, most were unaware of the purposes of their medications and said staff had not explained this to them. Relatives highlighted inconsistent communication regarding changes to care or medication, suggesting gaps in shared decision-making and information provision.
Opportunities for meaningful activities were limited. People said activities were only available on certain days. Some people described feeling isolated and excluded, which limited engagement in social or leisure activities.
Staff interactions were described as generally kind and attentive; however, we observed that engagement was often task-focused rather than person-centred. People reported that their preferences were not always considered in daily routines, such as the times of meals or activities.
People’s feedback about communication and accessibility of management was mixed. Some people felt able to raise concerns and described the management team as approachable. However, people told us that not all issues were acted upon effectively, leaving some people reluctant to escalate concerns with staff.
The feedback we received reflected inconsistencies in care, communication, and involvement. While staff were generally caring, people’s overall experiences were negatively affected by limited person-centred engagement, restricted choice, and ineffective management of safety and wellbeing in the communal environment.