Bearwardcote Hall Residential Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted good quality of life, based on best available evidence. At our last assessment we rated this key question good. At this assessment the rating has changed to Inadequate. This meant there was a risk that people’s care, support, and outcomes would not consistently meet expected standards.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s needs were not consistently assessed or reviewed to reflect changes in their physical, health, wellbeing, or communication needs. Care plans were often outdated, incomplete, or lacked sufficient detail to guide staff in delivering care safely and effectively.

Whilst staff knew people’s care and support needs, care records were not reviewed regularly, meaning that changes in people’s needs, health, or wellbeing were not always captured. For example, people who refused personal care did not have these refusals assessed or strategies put in place to support them safely. Similarly, some people were at risk of losing weight not had their assessments reviewed for over six months. Clinical monitoring tools, such as food charts, weight logs, and turn charts, were not consistently completed, limiting staff’s ability to respond to risks or changes in health.

Several people and relatives reported not being aware of their care plans and said they could be more involved in planning or reviewing their care. One person told us they did not know what their medicines were for, and relatives highlighted they were not consistently updated about changes to care or medication. Staff acknowledged that care plans were not always current and lacked sufficient guidance for responding to refusals of care or changing needs.

The lack of regular, detailed assessments and reviews limited people’s ability to receive care that met their current needs safely and effectively. People’s wellbeing, nutrition, and health were placed at risk when refusals of care or emerging needs were not adequately assessed or monitored. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

People did not consistently receive care, treatment, and support that was evidence-based or in line with recognised good practice standards. Systems to ensure staff were up to date with national guidance and legislation were not effectively implemented. The provider did not always complete Waterlow or MUST assessments for people who required them, placing them at increased risks of pressure ulcers and malnutrition. Care plans, records, and policies were not effective in ensuring people’s health, nutrition, or hydration needs were consistently met. There was no reliable system for monitoring or recording risks such as malnutrition or dehydration, and care plans did not always reflect people’s individual, or current needs. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

Most people reported not knowing what their care plans contained. Staff acknowledged that assessments and care planning tools were inconsistently completed, and there was limited guidance available for monitoring risks to people’s health or wellbeing.

The lack of evidence-based assessments and care planning placed people at risk of harm from preventable conditions, including pressure ulcers, malnutrition, and dehydration. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

People did not consistently experience coordinated care across staff, teams, and wider services. Information about their needs, preferences, and risks was not always shared effectively, limiting continuity of care and increasing the risk of errors or unmet needs.

We reviewed records that showed referrals for additional support for people were not always made in a timely manner. While some people were referred for additional support, such as dietetic, SALT, and other allied health services some positive feedback was received from these external professionals about staff implementing advice, not all referrals were made when people needed them. For example, when people’s mental health deteriorated, appropriate support was not promptly requested by staff. Staff did not seek external support, for example from the local authority safeguarding team when people refused care and were self-neglecting. Leaders did not delegate clinical tasks, such as monitoring people’s weight or completing food charts for those at risk of malnutrition. There was no systematic process to ensure all staff were aware of changes to people’s care needs. Staff reported that they mostly relied on the manager for direction and that handovers did not always cover important updates. People and relatives confirmed they were often not informed about changes in care or treatment plans.

The lack of consistent communication and coordination between staff, teams, and wider services placed people at risk of inconsistencies in their care and support.

We could not be assured that staff always recognised, monitored, or acted on changes in people’s health, and care plans did not reliably guide staff to promote healthier choices or prevent deterioration.
People’s care plans were often outdated, incomplete, or lacked detail to reflect individual healthcare needs, preferences, and levels of independence. Where staff attempted to empower and support people to manage their own health, they did not always do so safely. For example, staff did not complete a risk assessment for one person who was self-administering insulin. This placed the person at risk of incorrect dosing, hypoglycaemia, or other medicine-related harm. Staff did not consistently identify or escalate risks to people’s health and wellbeing, which limited opportunities to prevent deterioration. For example, when people’s mental health declined, appropriate referrals or interventions were not promptly made. People reported limited involvement in monitoring their health or understanding their care. External healthcare partners noted that staff implemented advice effectively when referrals were made, but inconsistencies in referral and monitoring processes left people at risk.

The lack of consistent assessment, monitoring, and health promotion increased the risk of deterioration in people’s physical and mental wellbeing. People were not consistently empowered to manage their own health, and delays in accessing appropriate healthcare placed them at increased risk of harm.

People’s care and treatment were not consistently monitored, and systems to improve outcomes were not effectively implemented. As a result, staff could not be assured that people’s health, wellbeing, or quality of life was consistently supported or improved.

Care records and clinical monitoring tools were often incomplete or not used consistently. For example, Waterlow assessments were not completed, so staff could not consistently identify people at risk of pressure ulcers. Food charts and weight logs were irregularly maintained, meaning unexplained weight loss or nutritional concerns could be missed. Daily fluid intake charts were not always completed leaving staff without assurance that people were adequately hydrated. Records of participation in activities and engagement were inconsistent, making it unclear whether people’s social and wellbeing needs were being met. The provider did not routinely benchmark clinical outcomes, participate in accreditation schemes, or use structured audits to evaluate and improve care. This was compounded by the provided working in isolation and not liaising with other services or homes to share good practice. As a result, there was limited evidence that care plans set measurable outcomes or that people’s progress was actively reviewed.

Staff acknowledged that monitoring was largely reactive rather than proactive, relying on the manager to identify concerns. The lack of consistent monitoring and quality improvement systems placed people at risk of unmet health and wellbeing needs. Without systematic review or evaluation, the service could not ensure that interventions were effective or that people’s outcomes were maximised. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

People’s capacity to consent was not assessed and best interest decisions were not recorded; therefore, we could not be assured that care and treatment decisions were always made in people’s best interests. Mental Capacity Assessments (MCAs) were not completed, and Deprivation of Liberty Safeguards (DoLS) authorisations were not consistently applied for, limiting the protection of people’s legal rights.

Several people with dementia or displayed confusion had no MCAs in place, and some did not have DoLS authorisations, despite the staff acknowledging that it would not be safe for them to leave the building unsupervised. While relatives were mostly involved in representing people’s views and wishes, MCAs and Best Interest decisions were not completed. Policies on consent and the Mental Capacity Act were in place, but staff, including leaders had limited understanding of how to apply them in practice, and there was no systematic tracker for MCA or DoLS completion. Records of advanced care decisions, including DNACPR forms, were in place, with involvement of people or their representatives evidenced.

The lack of consistent assessment and documentation of capacity, alongside incomplete application of DoLS, placed people at risk of having their rights under the Mental Capacity Act 2005 and other safeguarding legislation compromised. Decisions about care and treatment were not fully informed or legally compliant. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.