- Care home
Brushwood House
Assessment report published 9 September 2026
Contents
Ratings
Our view of the service
Date of Assessment: 15, 22, 30 July 2026. Brushwood House is a care home registered to provide nursing and personal care for up to 60 people. At the time of this assessment 39 people were living at the home.
We undertook this assessment following concerns we received about people’s safety, and leadership and governance of the service. We found the provider was in breach of regulations in relation to safe care and treatment, medicine management, staffing, dignity and respect, need for consent, person centred care, nutrition and hydration, safeguarding and governance.
This was the first assessment of this service since it was registered under the current provider in August 2024. A comprehensive assessment was undertaken, covering all 34 quality statements across the five key questions: Safe, Effective, Caring, Responsive, and Well-led.
We identified widespread and systemic concerns affecting the quality, safety and governance of the service. Significant failings were found in relation to person-centred care, dignity and respect, consent, safe care and treatment, medicines, safeguarding, nutrition and hydration, staffing and governance. These concerns were not isolated incidents and reflected weaknesses in leadership, oversight and quality assurance arrangements.
Governance systems were ineffective in identifying, monitoring and addressing risks. Care records were often inaccurate, incomplete or contradictory. Safeguarding systems did not demonstrate effective learning, and quality assurance processes failed to identify many of the concerns we found. Opportunities to learn from incidents, complaints and safeguarding concerns were frequently missed.
Risks relating to medicines, nutrition, hydration, choking, falls, skin integrity, infection prevention and control, and clinical deterioration were not consistently assessed or managed. There was a lack of effective oversight of safeguarding concerns, and lessons learned were not used to improve practice.
We identified concerns regarding privacy, dignity and confidentiality. Sensitive information was not always appropriately protected, and governance arrangements relating to audio recording through CCTV systems were inadequate.
Staffing and workforce oversight were insufficient. Training records showed significant gaps in mandatory training and evidence substantial amounts of training were completed during and after our assessment period, reducing assurance staff were appropriately trained prior to our assessment.
In instances where CQC has decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded. This service is being placed in special measures. The purpose of special measures is to ensure services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
People's experience of this service
Overall, feedback indicated people valued the kindness and commitment of many staff. However, recurring concerns regarding staffing levels, agency staff use, communication, responsiveness and leadership oversight reduced confidence people consistently received safe, well-coordinated, person-centred and high-quality care.
People and their family members gave mixed feedback about their experiences of living at Brushwood House. Many people spoke positively about the kindness and caring approach of staff and told us they felt safe living at the service. Comments included, "Yes I feel safe and cared for," "The staff are very kind to me" and "Staff are caring and hardworking." Family members described staff as "Kind and caring" and said they were generally reassured by the support their family members received.
However, people and family members consistently raised concerns about staffing levels, continuity of care and the increasing reliance on agency staff. One person told us, "There is not enough staff day or night, sometimes I wait ages of a night if I ring my call bell." Another person said, "I don't think there is enough day staff, I have to wait for them to come and change me." Family members shared similar concerns, commenting, "They are often short staffed, and they don't always seem to be skilled" and "There could be more staff at busy times."
Several family members expressed concerns about the impact of agency staffing and the quality and consistency of care. One family member told us, "Agency haven't a clue." The family member described intervening when staff were attempting to use a hoist incorrectly because it was, ‘Unsafe’. Another family member said, "I don't feel there is sufficient staff with the right skills." And reported regularly seeing communal areas left unsupervised.
People's experiences of communication and involvement were variable. Some family members felt well informed and supported, with comments such as, "I receive emails and phone calls to keep me informed" and "Staff keep me informed of everything." However, others described poor communication and limited involvement in care planning. One family member said, "Don't get invited to any care plan meetings or discussions over care plan" and another reported a concern had been raised with managers, but they had, "Heard nothing yet."
Feedback about leadership was mixed, although concerns regarding management visibility were a recurring theme. Family members told us the registered manager was, "Not here at the weekends" or "Never there of a weekend." One family member described being "Extremely unimpressed with the registered managers attitude and response to things" and felt concerns raised were not always addressed. They expressed the view, "If you raise issues you end up in trouble or staff are sacked."