Residents exposed to ‘physical harm’ after management failed to take action, review finds

Three care workers were convicted for ill-treatment and neglect after they continued to work together despite safeguarding concerns

A lack of “decisive action” and an inability to achieve “substantive improvements” led to a series of safeguarding failures at a BUPA care home in Cumbria, a report has found.

The safeguarding adults’ review (SAR), produced by the Cumbria Safeguarding Adults’ Board (CSAB), assessed the management of three care workers at Beacon Edge Nursing Home in Penrith, who were convicted for ill-treatment and neglect in 2014.

At least 15 patients were “harmed and exposed to physical assaults” by the workers, who sent “many thousands” of texts and took incriminating photographs, which were “degrading and humiliating” for the residential patients.

Despite “scrutiny and monitoring”, which included regular meetings about safeguarding, the report found that the management team at Beacon Edge “failed to improve the circumstances” of patients.

Unreceptive to change

Concerns about staff at the nursing home were first raised in July 2012 when the Speech and Language Therapy (SALT) team noted that management had failed to act on its recommendations.

After receiving a response from the registered manager of the home, the Cumbria Partnership Foundation Trust noted the service was “defensive and not receptive to the challenge”. It stated that neither the registered manager or BUPA’a managers had their “finger on the pulse”.

The Trust also reported that the registered general nurses “spent a substantial amount of time in the office with the door closed”. This meant qualified staff were unable to supervise the quality of care being delivered in the home.

Following a number of safeguarding alerts, a care worker witnessed two colleagues (BB and CB) engaging in “the unsafe lifting of a patient” and overheard them verbally abusing a service user. She was physically intimidated by BB when she offered to take over.

The employee immediately reported this to the senior social care and the registered manager, who suspended the staff and assured the Care Quality Commission (CQC) that the two employees would no longer work together.

However, the CQC noted in subsequent investigations that the two staff members continued to work on the same shifts. And, the investigation was unable to proceed to disciplinary because of “insufficient evidence”, BUPA said.

Further concerns 

On 23 August 2013, a safeguarding alert was raised with Cumbria’s adult safeguarding team. A second whistle blower saw the same two employees pulling a patient from a chair by his arms and pulling his neck.

Both were put on “light duties” as the safeguarding team advised taking a case management route was “more appropriate” to address the moving and handling concerns rather than safeguarding.

The following month, a worker who had then started at Beacon Edge was on duty with the CB and BB when she observed the latter physically hurt two patients, “yanking” their hair.

The new starter added that CB and BB took videos of themselves with patients, with one clip showing the male care worker getting into bed with a service user and scaring another. The new employee told her colleagues they were being cruel, but they insisted it was “just a laugh”.

The staff member verbally resigned after working a single shift and informed the registered manager she was leaving because of the ill-treatment of four patients.

The registered manager reported the ill-treatment to Adult Safeguarding and, following a strategy meeting, which included the police, CQC, Contracts and Health, a full criminal investigation began, and officers took statements from witnesses.

BB and CB were suspended from duty.

Arrests made

On 12 September, BB and CB were arrested on suspicion of offences under Section 44, Mental Capacity Act.

In addition to the five known patients who were victims of their physical and verbal cruelty, evidence on their mobile phones identified a further seven victims.

Messages from their phones revealed verbal threats made to patients in addition to anticipated assaults and disclosure of retaliation towards a colleague, who had reported their cruel behaviour.

Both CB and BB resigned from Beacon Edge in September. However, a third care worker, CS, was arrested after an examination of BB’s phone, which identified her as an active participant in the ill-treatment.

On 24 January, BB was charged with 8 counts of ill-treatment and wilful neglect and a sexual offence; CB was charged with 10 counts of ill-treatment and wilful neglect; and CS was charged with 3 counts of ill-treatment and wilful neglect.

Learning points

The SAR concluded the care workers’ jokes reflected “extraordinary potent and disrespectful views” of older people.

It added that their defence, in which they described their behaviour as “a bit of fun”, demonstrated “insensitivity at best and outright hostility at worst towards older people”.

Monthly professional meetings and the provision of training opportunities were normally “suggestive of a lot of scrutiny and monitoring”, the review concluded. However, it found that sessions “did not identify common ground or adopt an explicit overarching purpose” in this case.

“The safeguarding concerns did not diminish since there was no credible ‘operational grip’ on the failing work culture at Beacon Edge Nursing Home. This was the responsibility of BUPA Ltd,” it said.

BUPA commented on the case, saying it was “very difficult” to see how their behaviour could have been uncovered “sooner” given the care workers’ attempts to stating the employees’ attempts to hide their behaviour.

“[The three individuals] went to great lengths to cover their tracks and to avoid being caught out. They worked together on night shift and typically focused on residents who were not able to speak about their treatment.”


The SAR made nine recommendations, with BUPA being directly addressed on three occasions.

It suggested the care provider should tell the safeguarding adults’ board of the measures it has taken to assure commissioners that Beacon Edge’s engagement with patients and relatives and recruitment practices “are supportive of learning and improving practice”.

It also recommended that commissioners and lead professionals associated with the care home meet to address the identified failings and document how they would respond differently to future concerns about poor practice.

Finally, it asked that Beacon Edge is used as a “case study” for training at BUPA, Cumbria Clinical Commissioning Group and the CQC.

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