Bearwardcote Hall Residential Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm. The service was in breach of legal regulation in relation to people’s safe care and treatment, staffing and safeguarding.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not effectively listen to concerns about safety and did not investigate or report safety events appropriately. Lessons were not learnt to continually identify and embed good practice.

The provider did not have a consistent approach to incident recording or complaint management. Falls were the only events consistently logged, while incidents such as people hitting staff or other people, behaviours of distress, allegations of abuse by visitors, and unlawful restraint were not recorded, investigated or reported correctly, for example to the Local Authority or the CQC. When care staff raised concerns to management about unsafe practices, they were often met with ineffective actions from management.

People expressed that they could raise concerns with staff and management, but examples showed that concerns about their own safety or incidents affecting them were not always acted upon. Staff confirmed that management’s response to serious issues could be limited to verbal warnings or delayed actions, which affected trust in raising future concerns.

The lack of systematic investigation, reporting, and learning meant risks were not proactively managed, and opportunities to improve safety were missed. This increases the likelihood that people and staff could be exposed to preventable harm. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Referrals to safeguarding and mental health services were not always made in a timely or appropriate manner. People’s incidents, including allegations of neglect, inappropriate visitor conduct, and self-neglect, were not escalated, investigated, or reviewed, compromising safety. Care plans and risk assessments were often generic, incomplete, or outdated, and did not guide staff to manage risks consistently. Care plan reviews did not take place following incidents such as falls, and people and their relatives could not recall being meaningfully involved in care decisions. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

People reported limited communication about changes to their care or medication, and staff described relying solely on the manager for guidance, highlighting gaps in shared responsibility and coordination. However, some external partners, such as the district nurse, described effective engagement with the service and timely communication when delivering care, showing that collaborative working was possible when established.

The lack of robust systems and oversight meant that people were exposed to avoidable risks, and continuity of care was not consistently maintained, particularly when people required external support.

People were not consistently protected from abuse, neglect, or discrimination. The provider did not effectively recognise, report, or respond to safeguarding concerns, and systems to keep people safe were not consistently implemented.

Multiple incidents that met safeguarding thresholds were not reported to the local authority or CQC, including allegations of neglect, inappropriate visitor conduct, and unlawful restraint. Safeguarding records were incomplete, and there was no systematic oversight or review of concerns. Only one safeguarding incident had been logged in the last 12 months; however, during our assessment and review of other evidence, we found several additional safeguarding incidents that were not recognised, logged, investigated, or reported. We referred the incidents to the local safeguarding authority following the inspection.

Mental Capacity Assessments (MCAs) were largely absent, and Deprivation of Liberty Safeguards (DoLS) authorisations were not always applied for, despite some people lacking capacity to make decisions. Policies on safeguarding, MCA, and DoLS were in place but not implemented effectively.

People reported feeling unsafe at times, particularly when incidents involving visitors or staff were not appropriately addressed. Staff expressed uncertainty about when and how to raise safeguarding concerns and relied on the manager to make decisions. Management understanding of safeguarding principles was also limited. Observations confirmed that safeguarding principles were not consistently followed in practice. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

The lack of effective safeguarding systems, monitoring, and reporting placed people at risk of harm, with their rights under the Mental Capacity Act 2005, Equality Act 2010, and human rights legislation not consistently upheld.

People were not consistently involved in understanding or managing risks associated with their care. Risk assessments were absent or not up to date, and staff did not consistently communicate risks to people or involve them in planning how to manage them. For example, there were no risk assessments in place for people administering their own medications or for those at increased risk of absconding. Where risks were identified, guidance for staff was often unclear, and there was limited evidence that risk management was reviewed or updated in collaboration with people.

When people communicated their needs, emotions, or distress, staff lacked guidance and training on how to manage these situations in a positive way that protects people’s rights and dignity and maximises learning about the causes of distress. Staff had no training or clear guidance on supporting people who were distressed or presented with behaviours that challenged. We could not be assured that restraint and restrictive interventions were always recorded or justified in line with best practice, as we identified incidents of restraint that were not appropriately investigated.

As a result, people’s safety was not consistently supported. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

People were not consistently cared for in a safe environment, and the provider’s management of environmental safety, maintenance, and health and safety was ineffective, placing people at risk. Staff did not complete key actions identified in the legionella risk assessment (January 2025), increasing the risk of bacterial infection, and several taps lacked thermostatic mixing valves with hot water temperatures exceeding 44°C, creating a risk of scalding. Environmental checks, maintenance, and servicing were carried out on an ad hoc basis, and the provider did not maintain a formal maintenance log. This meant work was not prioritised, monitored, or completed systematically.

Staff did not ensure safety adaptations were adequate. Stairs were unsafe for people with reduced awareness of risk due to dementia, and unsecured wardrobes, missing window restrictors, and some rapidly collapsing sash windows placed people at risk of falls or injury. Scattered mobility equipment created further trip hazards. Following our feedback and requests for risk mitigation assurances, the provider addressed the urgent risks including scalding risk from radiators, windows, and hot taps.

During the inspection, we identified a strong smell of damp and mould in upstairs areas. Visual checks revealed damp patches on ceilings and walls, black mould on windowsills, and mould build-up on upper surfaces. Staff had not reported or addressed these issues, and there was no evidence of risk assessments or remedial actions, creating health risks for people who used the service. We referred this issue to the Environmental Health department within the local authority.

Fire safety measures were mostly in place, with drills, alarms, doors, and Personal Emergency Evacuation Plans (PEEPs) documented; however, the remaining hazards, including unsafe water temperatures, compromised safety adaptations, and unaddressed damp and mould, demonstrated serious concerns about environmental safety. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

People were not consistently supported by staff who were safely recruited, sufficiently trained, or supported to carry out their roles. There were significant gaps in recruitment, induction, and training processes, which placed people at risk of unsafe or inconsistent care. Safe recruitment checks were not consistently completed. For example, references obtained did not include sufficient information to confirm applicants’ employment history, job responsibilities, or any disciplinary or safeguarding concerns. This meant the provider could not be assured that all staff were suitable to work in a regulated care role.

Induction and training arrangements were insufficient. The provider’s induction programme included some hands-on practical training, such as fire safety and moving and handling. However, the majority of the induction consisted of online modules completed in a single day with minimal opportunity for practical learning or assessment of competence. Some staff had not refreshed safeguarding and infection prevention and control (IPC) training since 2022. The provider had not demonstrated how it assured itself that staff competence in these areas remained current. During the assessment, we found concerns relating to gaps in safeguarding practice and inconsistent infection prevention and control standards, which indicated that staff’s knowledge and confidence in these areas were not consistently maintained. Training was not tailored to people’s individual needs.

Staffing levels during the assessment were generally sufficient to meet people’s basic care needs, and there was no evidence of unsafe minimum staffing numbers. However, the lack of appropriately trained and competent staff limited the effectiveness and consistency of the care provided.

Not all supervisions and appraisals were completed in line with the provider’s own policy. A review of supervision records showed that they were not always carried out as frequently as expected and did not consistently cover subjects needed to support staff development, address performance, or reinforce safe practice.

As a result, people were placed at avoidable risk of harm due to insufficiently trained and poorly supported staff. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

The provider did not consistently manage the risk of infection in line with current national guidance. There was no sluice or suitable alternative to safely empty and clean used commodes that most people were using, and there was no guidance on how to do this hygienically. Staff reported washing commodes in people’s bathroom sinks, increasing the risk of cross-contamination and infection.

Staff did not maintain the premises and equipment in a clean and hygienic way. We found worn and soiled carpets throughout the service, with heavy dust accumulation, cobwebs, and dead insects on multiple surfaces in communal areas and people’s bedrooms. In the kitchen and pantry, surfaces were sticky, and mould was present inside the fridge. These unhygienic conditions placed people at risk of infection and cross-contamination. Staff did not dispose of continence pads according to recognised guidance, failing to place them in individual bags.

Staff did not consistently complete or document cleaning tasks, for example they had not recorded kitchen cleaning for several days. Laundry was not managed in line with guidance on clean and dirty zones, creating a risk of cross-contamination between soiled and clean items.

These failures exposed people, visitors, and other staff to avoidable infection risks. Staff lacked effective systems, guidance, and equipment to protect people, and leaders did not have adequate oversight or enforce consistent infection prevention and control practices. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

The provider did not ensure that medicines and treatments were managed effectively, safe and met people's needs, capacities in decision making, and preferences. Staff did not always involve people in planning.  There were no medication audits in place, which limited the provider's ability to identify risks, medication errors, or improve practice. 

Some people were prescribed medicines that carry higher risks if not managed safely, such as blood thinners and insulin. One person was administering their own insulin injections, but there was no risk assessment or monitoring plan in place to make sure this was being done safely. Staff did not use body maps for creams or skin patches, and there was no record of where these medicines had been applied. This meant there was a risk of medicines being used incorrectly or inconsistently, which could put people’s health and safety at risk. 

Care plans did not always include the most up-to-date information about people’s medicines or show when the GP had last reviewed them. The home had a GP-approved list of common “homely remedies” (like pain relief or cold medicines), but there were no individual care plans explaining when and how these should be used for each person. Medicines were generally stored securely, but the fridge was found unlocked during our inspection. We observed medication trolleys were left unattended during medication rounds. Medication administration record (MAR) charts were accessible to anyone, which posed a risk to confidentiality and safety. Controlled drugs were stored safely and in line with the law, and our count during the inspection matched the recorded stock. However, management oversight was limited. The registered manager had not completed regular audits, and a recent medicine error led the home to increase balance checks from monthly to weekly.  

Staff had completed medicines training and were assessed as competent. However, we could not be assured that staff were fully competent to administer medicines safely, as the training was delivered solely online and competency checks were carried out internally. This limited assurance that staff maintained the practical skills and knowledge needed for safe medicines administration.  

MAR charts were generally well maintained, with no gaps and clear records of how medicines had been given. However, two staff members remained on the signature list even though they no longer administered medicines, which could cause confusion about who is responsible for giving medicines. PRN (as required) medicines had clear protocols, including guidance on when to give them, maximum dosages, and review dates. Staff reported that all people were able to express their pain, and PRN medicines were not given routinely.  

The provider did not consistently manage medicines safely or in a way that met people’s needs, preferences, and capacities, and gaps in oversight, training, and record-keeping placed people at risk of errors and inconsistent care. Additionally, the concerns we found were not addressed promptly. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.