CQC rates Bradford care home inadequate

Published: 9 February 2024 Page last updated: 9 February 2024

A care service in Bradford has again been rated inadequate by the Care Quality Commission (CQC), and will remain in special measures, following an inspection carried out in December.

The Beeches Care Home, run by Victorguard Care Limited, is a residential home providing personal care to older people, some of whom were living with dementia. The service is registered for 60 people, at the time of this inspection there were 23 people living at the home.

This inspection was carried out as part of CQC’s continual checks on the safety and quality of healthcare services.

Following this inspection, as well as the home’s overall rating being re-rated inadequate, so have the ratings for being safe and well-led. The ratings for how effective and responsive the service is has dropped from good to inadequate. Caring has improved from inadequate to requires improvement.

The service will remain in special measures, which means it will continue to be kept under close review by CQC to keep people safe and it will continue to monitor to check sufficient improvements are being made. If CQC doesn’t see rapid and widespread improvements, further action will be taken, even if this results in the closure of the service.

Sheila Grant, CQC deputy director of operations in the north, said:

“When we inspected The Beeches Care Home, it was very concerning the provider hadn’t addressed our concerns raised in the previous inspection last April, and we won’t hesitate to take enforcement action if this isn’t addressed rapidly.

“We were still concerned that people weren’t living in a service where they had maximum choice and control of their lives with staff providing support in the least restrictive way possible and in their best interests.

“Leaders did not make sure there were enough staff to look after people. We saw people shouting out for help and looking for staff to support them, but they were too busy to help. This is unacceptable, people have the right to have their basic care needs met, and not live in distress. Staff also told us that sometimes they had to miss their breaks due to low staffing numbers and still couldn’t always meet people’s needs.

“Additionally, staff didn’t have time to carry out any engaging activities. People were sitting for long periods of time in their bedrooms and communal areas without any meaningful interaction, and only saw staff when they were providing personal care or giving people their meals.

“Also, there was a secure garden, but this wasn’t freely accessible to people. Keypad locks meant people could only access it with support from staff. EVen when people were supported to use the garden, records showed that it wasn’t safe for people to use.

“Leaders haven’t taken our previous feedback and used it to make the rapid improvements we told them to. We have told them they must provide us with an action plan to give us assurance improvements are being made at pace to keep people safe.

"The service will remain in special measures, and we will be keeping it under close review with monthly monitoring of the action plan. We will visit the home again and if we don’t see significant improvement, we won’t hesitate to take action, even if this results in the closure of the service."

Inspectors found:

  • Risks were not being well managed for people, and where risks had been identified staff were not keeping up to date care records
  • Inspectors were not assured the provider had effective systems for safeguarding vulnerable people
  • Medicines were not well managed, and the provider's systems had not identified shortfalls
  • Care plans were inconsistent in detail. Some lacked relevant information such as appropriate risk assessments, and some care plans failed to capture people’s choices, wishes and preferences
  • Nutritional requirements were not being well managed and care staff failed to keep accurate records of people’s food and fluid intake
  • Risks had not been fully assessed or mitigated to ensure people’s safety. This related to pressure relieving care and equipment, catheter care, reporting of incidents and accidents, and managing distressed behaviours. There was a lack of evidence for lessons learnt when things had gone wrong.


  • The provider was working well with other professionals
  • Staff spoke highly of the new manager and felt the atmosphere had improved and staff were working better as a team.

The report will be published on CQC’s website in the next few days.

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.