A grieving daughter has said it is "an insult" that the former manager of a care home where two residents died is in another managerial position overseeing care homes, despite being prevented from registering with the Care Quality Commission (CQC).

Eleanor Watson-West told an inquest in September she was now employed as an area manager at Country Court Care, which she joined after leaving Viera Gray House, run by Greensleeves Care, in Barnes.

Ms Watson-West was the registered manager of Viera Gray when Neil Sweetmore, 86, died in hospital on September 11, 2020, 17 days after being attacked for the third time by resident John Edgar.

Both men had dementia. A coroner ruled this year that John's final assault on Neil "could and should have been avoided".

Less than two years later, Paula Geeves-Booth, 93, was found dead on the floor at Viera Gray after falling from her bed on June 16, 2022, and breaking her neck. A safeguarding report found she had experienced neglect.

The CQC placed Viera Gray in special measures after finding a catalogue of failings at an inspection in October 2022 following Paula's death.

The Local Democracy Reporting Service (LDRS) understands the regulator has also prevented Ms Watson-West, who left the home before the inspection, from registering with it as a manager again due to its concerns about her.

But while workers need to register as a manager with the CQC if they are in charge of delivering regulated activities at a location, meaning they are legally responsible for how it is run alongside the provider, the watchdog does not directly regulate every individual involved in a care home's management.

Paula's daughter Sarah Booth, 64, told the LDRS she feels the CQC is ineffective if people who have been prevented from becoming a registered manager with it can still hold a managerial position in the sector.

Sarah said: "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? 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."

The CQC told the LDRS its priority is the health and wellbeing of people using its services. It said it has liaised with Country Court for information on how it is managing recruitment safely in its organisation.

An inquest into Neil's death in September concluded he died of pneumonia caused by a head injury. Coroner Lydia Brown ruled the assaults he experienced contributed to his head injury, along with at least four unwitnessed falls he had at Viera Gray and age-related decline.

She said the end of Neil's life "was sadly marred by both natural disease processes, but also violence in the very place where he should have been safe".

Ms Brown found John's escalating violence and aggression towards staff and residents from April 2020, driven by cognitive decline, "was not properly managed" by Viera Gray.

She said incidents were not all "properly recorded, escalated, reported" and there were "inadequate systems, training and supervision" at the home.

The coroner found that inadequate communication between Viera Gray and external agencies meant nobody had the full picture to appropriately safeguard the men.

She ruled the unit where John attacked Neil for the final time was "not a safe place to be" and did not have enough staff to manage the risk he faced.

The incident was "predictable and therefore could and should have been avoided", she said.

Ms Watson-West told the inquest she had contacted different agencies for more support with John before Neil's death, including mental health services, but said: "I felt like I wasn't really getting the support that I needed, that I wasn't really being listened to."

She added: "I feel I did everything in my power to try and support both John and Neil and my team."

Paula died less than two years after Neil on June 16, 2022. Sarah said staff were aware of the danger her mum faced before she died as she fell from her bed in similar circumstances only three months earlier, which left her with facial wounds, a bruised nose and neck pain.

Sarah and Paula Geeves-Booth (credit: Image supplied).

She was also found injured on the floor on November 23, 2021, after falling from her chair as she had not been helped to bed.

The coroner's report in October 2024, which ruled Paula's death was an accident, found staff were not alerted to her fatal fall as her sensor mat had been unplugged and there was no alternative emergency alarm or staff check between 7.40am, when she was last seen asleep, and 9.14am.

It said she fell at some point between these times, likely from a sitting position, which fractured her neck in two places.

A report by Richmond and Wandsworth Safeguarding Adults Board found Paula had experienced neglect as her support plan was not followed.

It said staff lacked transparency during enquiries and appeared to have decided to omit that her sensor mat had been unplugged the night before she died.

The report revealed a motion sensor to detect Paula's movement in bed had been trialled, and would have recorded when she sat up, but it was not attached at the time of her death as staff were not trained in how to use it.

Staff failed to follow policy as they put her back in bed when she was found deceased, it added.

The CQC had already rated Viera Gray as 'Requires Improvement' for safety, but 'Good' overall, in September 2021.

Inspectors visited partly due to concerns about Neil's death, staffing levels and risk management. They found residents' risk management plans did not always give staff clear guidance on how to keep them safe from harm.

A year later, after partly re-inspecting the home in October 2022, following Paula's death, the CQC published a damning report cataloguing failures around people's safety and management of the home.

It slapped the home with the worst possible rating of 'Inadequate' and placed it in special measures.

Inspectors found residents were not protected from the risk of harm and abuse, there were not enough staff to keep people safe, incidents were not always recorded or managed effectively and lessons were not always learned when things went wrong.

They described a closed culture whereby staff were not always confident in speaking out against poor practice.

Sarah told the LDRS she feels her mum's death could have been avoided if the CQC had thoroughly inspected the home after Neil died and made sure adequate measures were put in place to make it safe.

She said she believes her mum's death, and the two falls leading up to it, were preventable and poor management of Viera Gray resulted in her receiving inadequate care.

Sarah said staff were aware of the danger her mum faced before she died as she fell from her bed in similar circumstances only three months earlier (credit: Facundo Arrizabalaga/MyLondon).

'Not even worth the paper it's written on'

Sarah said she has been let down by the "broken" care sector in her battle for answers and accountability for failings in relation to her mum's care, only to be dealt a new blow by the discovery that someone who has been prevented from registering as a manager with the CQC can still hold a managerial position overseeing care homes.

She wants to see the establishment of a professional body to which every care worker has to register, so that they are held directly accountable for any failures in the care they provide, to improve the safety of the sector.

Sarah said: "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. There is no incentive other than their own moral compass.

"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."

Viera Gray's rating moved up to 'Good' in all areas following the CQC's latest inspection in April, the result of which was published in May.

Inspectors found people felt "safe and happy" living there, with enough staff to meet people's needs, although they raised some concerns about the way risk was managed.

The report said staff felt supported to give feedback and the home had a "culture of continuous improvement".

A Greensleeves spokesperson said: "Today, Viera Gray House is a thriving home, recognised by the Care Quality Commission with a 'Good' rating in May this year. We remain firmly committed to providing a safe, caring, and high-quality environment for everyone we care for."

A CQC spokesperson told the LDRS: "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.

"CQC carried out inspections at the home after being informed about each death. We took enforcement action, including putting conditions on the home's registration, and have monitored the service closely. The findings from these inspections are available on our website.

"We carried out an investigation into each death to determine if any regulatory action was required against Greensleeves Homes Trust who run the home, and Eleanor Watson-West, who was the registered manager at the time of both deaths.

"In the case of Neil Sweetmore, we started a prosecution against Eleanor Watson-West, but were unable to proceed after two key witnesses withdrew. There wasn't sufficient evidence to pursue a prosecution in relation to Paula Geeves-Booth.

"We are aware that Eleanor Watson-West is employed by Country Court Care Homes. She is not a registered manager and cannot directly manage a care home without CQC registration. While her current position does not require CQC registration, we have liaised with Country Court Care Homes for information on how they are managing recruitment safely in their organisation.

"CQC's priority, at all times, is the health and wellbeing of people using health and social care services, and all information we receive informs our monitoring of services and future inspections. We'd encourage anyone who has concerns about a health and social care service to let us know. This can be done by emailing [email protected] or via our customer service centre on 03000 616161."

Country Court Care declined to comment. Ms Watson-West was also approached for comment via Country Court.

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