Brentwood Care Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Incidents, complaints and safeguarding concerns were recognised, reported and generally responded to appropriately. Leaders described learning from events through reflective practice, supervision and follow‑up actions, which supported a developing culture of safety and openness. Staff felt able to raise concerns, and issues were investigated with an emphasis on learning and improvement.

The service demonstrated positive aspects of a learning culture, with leaders and staff open to feedback and responsive to issues identified during the inspection. Where concerns were found, action was taken promptly, including updates to care plans and clarification of guidance to reduce risk. Staff spoke confidently about learning from incidents, complaints and near misses, supported through supervision and training.

However, some people and relatives said they were not always routinely asked for feedback about their care. While concerns raised were listened to, relatives were not consistently assured that feedback led to visible change. Leaders acknowledged this and described plans to strengthen daily walk rounds and improve the use of surveys and relative forums at local and senior levels to better capture feedback and demonstrate how learning informs service improvement.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Safe systems were in place to support people’s pathways and transitions into and within the service. Pre‑admission assessments and multidisciplinary input were used to help ensure people’s needs could be met safely. Staff worked with external professionals to support transitions, such as hospital visits, and shared information to promote continuity of care. However, some information following transitions was recorded in handover notes but not always consistently reflected across care plans and risk assessments. Strengthening recording systems in this area would further improve oversight and assurance.

The provider worked with people and healthcare partners to understand what being safe meant to them and how this could best be achieved. Staff focused on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Safeguarding concerns were shared promptly and appropriately.

People were supported to live safely, and staff had received safeguarding training to help them recognise and respond to concerns. People and relatives told us they felt safe and confident in the care provided. One person said, “I know I am safe here, the staff know what they are doing and always come when I buzz.” Safeguarding concerns were reported appropriately, and the service worked closely with the local authority to help protect people from harm. While most staff understood internal safeguarding processes, some were less clear about external escalation routes. The registered manager and operations director recognised this as an opportunity for improvement and undertook a lessons‑learned approach to strengthen safeguarding training, supervision and staff understanding of external reporting pathways, reinforcing a culture where safeguarding was everyone’s responsibility.

Training records confirmed staff had received safeguarding training and understood Deprivation of Liberty Safeguards (DoLS) processes. DoLS referrals were made and monitored by the registered manager where restrictions were in place. We reviewed compliance with the Mental Capacity Act 2005 and found DoLS authorisations were completed appropriately and oversight was effective.

People were supported to manage risks, and staff understood individuals’ safety needs. Measures such as sensor mats, door gates and bedrails were used to reduce harm, and some people and relatives were involved in discussions about risk. For example, one person chose to have a bedroom door gate tomaintainprivacy, withappropriate mentalcapacity assessment and consent in place, and staff understood how to manage this safely.

Since the last inspection, guidance for staff had improved, particularly around catheter care and risk management. Monitoring tools had also been strengthened, supporting more consistent recording. Further action had been taken to improve the management of specific health risks and safer moving and handling practices,demonstratingprogress in addressingpreviousconcerns.

However, involvement of people and relatives in assessing and reviewing risks was not always consistent. Records did not always clearly show how people’s views informed decisions, and some carers told us they were not involved in completing risk assessments. There was also some inconsistent information across care plans and risk assessments, including guidance on mobility, sensor use and food textures, which limited assurance of consistent and collaborative risk management.

Leaders responded promptly to concerns raised during the inspection. For example, inconsistencies relating to a choking risk and prescribed InternationalDysphagiaDietStandardisationInitiative (IDDSI)levels were reviewed and correctedimmediately, with further professional guidancesought.IDDSIis a recognisedcolour codedsystem whichstandardises howwe prepare and describe texturemodifiedfoodsand thickened liquids to keep people with swallowing difficulties safe.

While this showed responsiveness, systems were not yet fully robust to ensure people were consistently involved in managing risks.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The environment wasgenerally safe, wellmaintainedand suitable to support people’s needs. People’s bedrooms were personalised, with names displayed on doors, and communal areas were welcoming and appropriately arranged to promote comfort and safety. Equipment and environmental safety checks were up to date, including gas safety, electrical testing, lift servicing, hoist and bed checks, fire safetysystemsand legionella controls. Regular fire risk assessments, drills, emergency lightingchecksand personalised emergency evacuation plans were in place, providing reassurance that people could be supported safely in an emergency. However, some environmental issues wereobserved, including occasional malodours on theground floorandsome bedrooms requiring redecoration.These did not present an immediate safety risk but highlighted the need for continued routine checks to ensure the environment consistently supported people’s safety,dignityand comfort.

The service was staffed by people who had the right skills,experienceand support to meet people’s needs safely and effectively. People and relatives consistently described staff as kind, knowledgeable and attentive. One person told us, “The staff know what they are doing and arevery good to me,” while another said,“Yes, I feel there is enough staff around; they are veryfriendly and come in and talk to me.” Relatives also provided reassurance about staffing levels, with one saying, “Always seems to be enough staff on duty, and we are regularly updated about[persons]care.” Some relativesand peopleacknowledged staff could be busy at certain times, particularly when responding to call bells, and one said, “The staff are very good, but sometimes[person]doeshave to wait whentheybuzz.”The providerhad acknowledged this andhadupgradedthe call bell system, which would allow for regular monitoring, auditing and strengthened oversight ofstaffresponse times.We reviewed call bell data from03 May 2026 to10 May 2026 inclusiveand of the 2228 calls, the average response time was 2.17 minutes.

Staff worked well together as a team anddemonstrateda good understanding of people’s needs. Recruitment processes were in place to ensure staff were suitable to work with vulnerable people, and staff received training and ongoing support to carry out their roles safely, supporting effective and responsive care delivery.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Improvements had been made since our last inspection, and the provider had invested in refurbishment, redecoration and replacement flooring across some of the service with further improvements planned.

Regular infection prevention and personal care audits were completed, which showed that cleaning practices, use of Personal Protective Equipment (PPE) and hand hygiene were largely effective and consistently followed. Audit outcomes identified good compliance with environmental cleanliness and equipment hygiene, including routine cleaning and monitoring of water systems and shower heads to reduce the risk of legionella.

Where audits highlighted areas for improvement, these were addressed through staff reminders, supervision and increased monitoring. People told us their rooms were cleaned regularly, and staff were observed using PPE appropriately during personal care. Overall, audit processes supported ongoing learning and improvement and helped ensure infection prevention and control practices were embedded and effective.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

There were systems and processes in place to manage and administer medicines safely however, staff were not always following these. People were not always receiving their medicines as prescribed or in line with national guidance, for example, medicines administered via a Percutaneous Endoscopic Gastrostomy [PEG], insulin and medicines with special administration instructions. We brought our concerns to attention of the provider who provided a robust and timely response including lessons learned for staff. No harm had come to people.

Staff used an electronic medicines system [e-MAR] to accurately record medicine administration including time sensitive medicines, controlled drugs, when required [PRN] medicines and medicines patches however, staff were not recording the daily patch check. The eMAR system was monitored by senior staff throughout the day to ensure people did not miss their medicines.

Care plans were in place to support staff to administer people’s medicines safely; these were person centred and regularly reviewed and updated.

Where people experienced distress and agitation there were behaviour support plans and when required [PRN] protocols in place. There was information about peoples triggers and what de-escalation techniques staff could use to support the person. We saw staff usually recorded incidents and interventions using recognised reporting tools.

People had access to GPs and other healthcare professionals such as Hospice staff, to support their health. The GP regularly monitored and reviewed medicines used to treat mental health conditions. The service kept a log of these medicines with their review dates.

There were risk assessments in place for people receiving medicines that increased their risk of bleeding and bruising. Where people were prescribed creams containing paraffin there were fire risk assessments in place.

Medicines were ordered, received and stored safely in line with legal requirements and manufacturers temperature guidelines. Regular medicines audits were completed. Where areas for improvement had been identified, these had been documented and actioned.

Staff had received training and competency assessments from the provider and external trainers, to administer and manage medicines. This included administering medicines via a PEG.