A former manager whose Barnes care home saw two residents die preventable deaths was employed as an area manager overseeing multiple care homes, despite being barred from registering with the Care Quality Commission.
Eleanor Watson-West managed Viera Gray House in Barnes when Neil Sweetmore, 86, died in September 2020 after being attacked for the third time by another resident with dementia. A coroner ruled this year the assault “could and should have been avoided.”
Less than two years later, Paula Geeves-Booth, 93, died after falling from her bed and breaking her neck. A safeguarding report found she had experienced neglect.
The Local Democracy Reporting Service (LDRS) has now established that Watson-West told an inquest in September she had joined Country Court Care as an area manager – a senior role overseeing care homes – after leaving Viera Gray House.
The CQC confirmed to the LDRS it has prevented Watson-West from registering with it as a manager due to concerns about her conduct. But the regulator does not directly regulate every individual involved in a care home’s management.
Workers must register as a manager with the CQC only if they are in charge of delivering regulated activities at a specific location – meaning they are legally responsible for how it is run alongside the provider. Area managers overseeing multiple homes do not require CQC registration.
‘Not even worth the paper it’s written on’
Paula’s daughter Sarah Booth, 64, told the LDRS the loophole undermines the CQC’s effectiveness.
“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,” she said. “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.”
She added: “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.”
Sarah Booth is calling for the establishment of a professional body to which all care workers must register, so they can be held directly accountable for failures in care they provide.
The deaths at Viera Gray House
Putney.news reported in September on the inquest into Neil Sweetmore’s death. The coroner ruled he died of pneumonia caused by a head injury, and that assaults he experienced contributed to his injury, along with at least four unwitnessed falls and age-related decline.
Coroner Lydia Brown 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.”
She found that resident John Edgar’s escalating violence from April 2020 “was not properly managed” by Viera Gray. Incidents were not all “properly recorded, escalated, reported” and there were “inadequate systems, training and supervision” at the home, she ruled.
The coroner found inadequate communication between Viera Gray and external agencies meant nobody had the full picture to 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.
Watson-West told the inquest she had contacted different agencies for support with John before Neil’s death, including mental health services. “I feel I did everything in my power to try and support both John and Neil and my team,” she said.
Paula Geeves-Booth died on 16 June 2022. According to the LDRS, staff were aware of the danger she faced as she had fallen from her bed three months earlier, suffering facial wounds, a bruised nose and neck pain. She was also found injured on the floor in November 2021 after falling from her chair as she had not been helped to bed.
A coroner’s report in October 2024 ruled Paula’s death was an accident. It 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.
According to the LDRS, a safeguarding report 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.
‘Inadequate’ rating and special measures
The CQC had rated Viera Gray as ‘Requires Improvement’ for safety in September 2021, partly due to concerns about Neil’s death, staffing levels and risk management.
After re-inspecting the home in October 2022 following Paula’s death, the CQC published a report cataloguing failures around safety and management. It rated the home ‘Inadequate’ – the worst possible rating – and placed it in special measures.
Inspectors found residents were not protected from 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 learned when things went wrong. They described a closed culture where staff were not always confident in speaking out against poor practice.
Watson-West left the home before this inspection.
Viera Gray’s rating moved up to ‘Good’ in all areas following the CQC’s latest inspection in April 2025. Inspectors found people felt “safe and happy” living there, with enough staff to meet people’s needs. The report said staff felt supported to give feedback and the home had a “culture of continuous improvement.”
The responses
A Greensleeves spokesperson told the LDRS: “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 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. 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.”
Country Court Care declined to comment to the LDRS.
