Bearwardcote Hall Residential Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

This service scored 36 (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 had policies in place, including those covering equality, diversity, and human rights, and a mission statement outlining the service’s values. However, these policies and statements were not consistently reflected in the culture or practice across the service. While most staff were kind and caring, the overall culture felt closed. This meant that communication was limited, some staff did not feel concerns and issues were addressed consistently. This created an environment where staff felt unsafe, and uncertain about raising problems or sharing ideas. Evidence showed that concerns raised were not always investigated in line with complaints or safeguarding policies, which created a sense that issues may have been dismissed.

Staff understanding of equality, diversity, and human rights was inconsistent. Some staff reported feeling discriminated against by colleagues, and leaders’ responses to these concerns were limited, and ineffective.

Leaders had not clearly communicated a shared vision or strategy across all staff within the service. Staff were not consistently aware of how their roles contributed to the service’s strategic goals, and there was limited monitoring or review to ensure progress against these goals.

Overall, the service’s policies were in place, but the culture, communication, and leadership did not consistently support a shared direction or positive, inclusive environment. This increased the risk that staff were not fully aligned with the service’s values and that people using the service did not consistently experience care based on these principles.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

Leaders at the home did demonstrate the experience, capacity, or oversight needed to ensure the service delivered safe, high-quality care. While the registered manager was in post, evidence showed weaknesses in leadership, including recruitment, induction, supervision, and training processes, which left staff underprepared and limited the service’s ability to manage risk effectively.

Leaders were visible and approachable, but they lacked the expertise and systems to consistently ensure staff were supported and safe, and that quality and safety risks were managed effectively. Policies were in place to promote honesty, integrity, and duty of candour, but leaders did not always act in line with these principles. Audits, spot checks, or other monitoring of staff practice and service quality were rarely conducted, and when concerns were raised, leaders often did not take sufficient action. These unaddressed issues posed a serious risk of harm to people before our inspection.

Staff understanding of equality, diversity, and human rights was inconsistent, and leaders took limited action to address workplace inequalities or poor practice. Overall, leaders were not sufficiently alert to the service’s cultural and operational problems, and this limited their ability to protect people, support staff, and deliver the service’s vision. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

Staff had some opportunities to raise concerns, but the service did not consistently support openness, honesty, or transparency. Staff surveys, supervisions, and meeting minutes evidenced that staff could speak up, but systems did not work effectively. The last staff survey took place in 2024, and managers analysed the results minimally, limiting learning from feedback. Monthly staff meetings allowed some concerns to be raised, but leaders rarely acted on the feedback given.

Managers communicated inconsistently with staff about complaints and did not always investigate concerns thoroughly. They did not consistently share lessons from incidents, which reduced staff confidence that problems would be addressed.

Although the service had policies on freedom to speak up, whistleblowing, and complaints, and staff handbooks explained how to raise concerns, staff often did not recognise care quality issues or know when to escalate them. Leaders often left issues unaddressed, which undermined staff confidence in raising concerns.

Overall, the service had policies and opportunities for staff to speak up, but leaders did not consistently act on concerns, learn from feedback, or empower staff, which left the culture weak and unresponsive. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

The service had policies covering equality, diversity, and flexible working arrangements, however leaders did not consistently use these policies to promote an inclusive workforce or address disparities among staff. Staff understanding of equality, diversity, and human rights was inconsistent, and not all staff had access to training covering protected characteristics, bullying, or harassment.

The provider had limited processes to promote workforce well-being. Staff received verbal recognition, but no formal initiatives supported their development or welfare. Supervisions were not always effective: they rarely included reflection on practice, discussions about the quality of care, observations of staff practice, or review the understanding of people’s care plans. Key areas such as safeguarding, whistleblowing, incident reporting, and refresher training needs were not routinely addressed. Supervisions also lacked focus on reinforcing confidentiality, dignity, respect, or supporting personal development and career progression. Leaders did not use supervision to reinforce the service’s vision, values, or expectations for person-centred, compassionate care.

Recruitment records showed that inclusive practices were not consistently applied, and leaders did not monitor workforce diversity or take action to address inequalities. The service did not have workforce equality strategies, objectives, or action plans, and leaders rarely reviewed or improved the organisational culture in relation to equality, diversity, and inclusion.

There was limited evidence that leaders addressed bullying, harassment, or structural inequalities proactively. One incident of inappropriate behaviour towards a staff member had been reported and investigated, showing some action, but this was not consistent. Leaders did not systematically take steps to remove bias, make reasonable adjustments for disabled staff, or ensure that staff and leaders reflected the population of people using the service. Opportunities for staff to raise concerns existed through supervision and staff meetings, but feedback rarely led to meaningful change, particularly for staff from protected or marginalised groups.

Overall, although policies existed, leaders did not actively promote equality, diversity, or inclusion in practice. Staff received inconsistent guidance, supervision did not reinforce inclusive values, and leaders did not act to address disparities or improve workforce culture, leaving some staff unsupported and the organisational culture weak.

Leaders did not consistently establish clear roles, responsibilities, or accountability. Leaders conducted audits, action plans, and spot checks inconsistently, or not at all. Where these processes were carried out, they often failed to identify key risks or trigger appropriate follow-up actions. As a result, significant risks to people’s care and safety went unaddressed for extended periods. Leaders did not consistently use findings to drive improvements, leaving weaknesses in oversight and quality assurance remained uncorrected. Communication with staff about policies and procedures was inconsistent, which limited understanding and compliance.

Digital records and data protection systems were in place, but leaders had not fully ensured staff followed procedures for confidentiality or secure handling of sensitive information. Emergency preparedness plans were incomplete, for example there were inconsistencies in arrangements for the registered manager’s absence.

Leaders did not fully implement workforce planning or performance management systems. Records of recruitment, rotas, training, supervisions, and staff development were inconsistent. Regulatory notifications were not reliably made, and there was limited follow-up after incidents, and safeguarding concerns.

Overall, governance, management, and sustainability systems were insufficient to guarantee safe, high-quality, and resilient care. Following our follow up site visit, the provider sent us an action plan describing how they were planning to mitigate these risks.

Leaders did not consistently work with external partners to improve care or share learning. Policies emphasised collaboration and continuous improvement, but in practice staff and leaders rarely implemented them.

The service did not actively participate in local health and social care forums, and meeting records showed minimal engagement with external organisations. Referrals to other community partners were inconsistent, which reduced opportunities for joined-up care and timely support for people using the service.

Staff, people using the service, and relatives had limited involvement in developing community networks or contributing to business and action plans. Meeting minutes and surveys indicated that shared learning was rarely discussed, which limited improvement opportunities and reduced the oversight of potential risks.

Overall, leaders had not established strong partnerships or active engagement with the local community, which weakened communication, collaboration, and the potential for shared learning.

Leaders did not consistently promote learning, improvement, or innovation across the service. Policies and procedures existed, but in practice they were rarely reviewed or updated based on feedback, incidents, or best practice guidance.

The service did not engage with quality accreditation schemes or use feedback to drive measurable improvements. Quality assurance systems, action plans, and audits were inconsistent or absent, which limited the service’s ability to identify risks, monitor progress, or learn from mistakes. Meeting records showed minimal collective problem-solving, and staff were not encouraged to contribute new ideas or suggestions.

Training and development opportunities relating to quality improvement or innovation were limited. The provider had not engaged with research projects, and there was no evidence that learning from external sources was applied to improve care. Technology was used in routine ways but had not been applied creatively to enhance outcomes.

Overall, leaders had not established a consistent approach to learning or innovation. Staff had few opportunities to reflect on practice, and systems to monitor the impact of change were largely ineffective, which limited improvement and reduced the potential for better outcomes.