A grieving daughter has described it as "an insult" that the former manager of a London care home where two residents died preventable deaths now holds a senior position overseeing multiple care facilities, despite being barred from registering with the Care Quality Commission.
Two tragic deaths under same management
Eleanor Watson-West was the registered manager at Viera Gray House in Barnes when two residents died in separate incidents that coroners and safeguarding reports found could have been prevented.
In the first tragedy, 86-year-old Neil Sweetmore died in hospital on September 11, 2020, seventeen days after being attacked for the third time by fellow resident John Edgar. Both men had dementia. Coroner Lydia Brown ruled this year that John's final assault on Neil "could and should have been avoided".
Less than two years later, on June 16, 2022, 93-year-old Paula Geeves-Booth was found dead on the floor at Viera Gray after falling from her bed and breaking her neck. A safeguarding report concluded she had experienced neglect before her death.
Systemic failures uncovered
The coroner found that Neil Sweetmore's final days "were sadly marred by both natural disease processes, but also violence in the very place where he should have been safe". She determined that John Edgar's escalating violence and aggression towards staff and residents from April 2020 "was not properly managed" by the care home.
Incidents were not all "properly recorded, escalated, reported" and there were "inadequate systems, training and supervision" at the home, the inquest heard. The unit where John attacked Neil for the final time was "not a safe place to be" and didn't have enough staff to manage the risk he faced.
In Paula Geeves-Booth's case, staff were aware of the danger she faced as she had fallen from her bed in similar circumstances just three months earlier, leaving her with facial wounds and neck pain. She had also been found injured on the floor in November 2021 after falling from her chair when she hadn't been helped to bed.
The coroner's report found staff weren't alerted to her fatal fall because her sensor mat had been unplugged and there was no alternative emergency alarm or staff check between 7.40am and 9.14am on the day she died.
Regulatory action and loophole exposed
The CQC placed Viera Gray in special measures after uncovering a catalogue of failings during an inspection in October 2022 following Paula's death. The regulator also prevented Ms Watson-West from registering with it as a manager again due to concerns about her performance.
However, while workers need to register as a manager with the CQC if they're in charge of delivering regulated activities at a location, the watchdog doesn't directly regulate every individual involved in a care home's management.
This has allowed Ms Watson-West to take up a position as an area manager at Country Court Care, where she oversees multiple care homes without requiring direct CQC registration.
Paula's daughter, Sarah Booth, 64, told the Local Democracy Reporting Service: "I feel that if a manager has been refused registration with the CQC, for any reason, this should categorically mean all managerial positions, not just registered manager. Otherwise, what's the point?"
She added: "Managers, in any capacity, have a huge amount of responsibility and to be allowed one and not the other makes no sense and, I feel, puts people at risk. It is also an insult to the families who have lost loved ones."
Calls for sector reform
Sarah is now campaigning for the establishment of a professional body to which every care worker must register, ensuring they're held directly accountable for any failures in the care they provide.
"Having no facilities in the UK for holding individual staff accountable for their actions does not foster a safe environment for the people they look after," she said. "There is no incentive other than their own moral compass."
She described her disappointment at discovering the limitation of the CQC's powers: "One small grain of comfort I got was knowing the manager had at least been prevented from registering with the CQC and unable to be the registered manager of another home - now it seems that is not even worth the paper it's written on."
The CQC told the LDRS that while Ms Watson-West's current position doesn't require CQC registration, they have liaised with Country Court Care Homes for information on how they're managing recruitment safely in their organisation.
A spokesperson said: "Neil Sweetmore and Paula Geeves-Booth should have been safe at Viera Gray House. Their deaths were tragic, and our condolences remain with their loved ones."
Viera Gray House has since improved its rating to 'Good' in all areas following the CQC's latest inspection in April, with the result published in May. Greensleeves Care said the home is now "thriving" and they remain "firmly committed to providing a safe, caring, and high-quality environment".
Country Court Care declined to comment when approached, and Ms Watson-West was also approached for comment via her current employer.
