Brushwood House

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence The provider and registered manager involved people and treated them with compassion, kindness, dignity and respect.

This is the first assessment for this service under the new provider. This key question has been rated Inadequate. This meant people were not treated with compassion and there were breaches of dignity; staff caring attitudes had significant shortfalls.

The provider was in breach of legal regulation in relation to dignity and respect.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People were not treated with dignity and respect. For example, observations, records and discussions with staff identified practices which did not always promote people's individuality, privacy or dignity, and at times focused on tasks rather than the person. Staff were observed using disrespectful and dehumanising language which reduced people to their care needs, conditions or equipment rather than recognising them as individuals. This included referring to people as ‘The walkers’, ‘She’s a hoist’, ‘He’s a pureed’, ‘Seeing to the feeds’ and ‘He digs.’

Confidential information about people's care and support needs was displayed openly throughout the home. We observed information visible on bedroom doors, walls and within communal areas which disclosed personal details about people, including continence needs, communication needs, hearing aid requirements, moving and handling instructions, fluid monitoring requirements, nil-by-mouth status and preferred gender of care staff.

There was no evidence to show appropriate consideration had been given to the impact audio CCTV may have on people's privacy, dignity and confidentiality.

People were not supported in a way recognised and reflected their individual preferences, needs and choices. For example, staff did not always demonstrate sufficient understanding of people's individual communication and emotional support needs. We identified examples where people's preferences, routines and personalised approaches to care were not always understood or followed by staff, resulting in care being delivered according to operational arrangements rather than individual need. A person repeatedly indicated they did not want the breakfast they had been provided and pushed the meal away on several occasions. An agency member of staff continued to encourage the person to eat the meal despite their clearly expressed preference. Although the meal was eventually removed, an alternative hot breakfast was not offered.

A persons care plan contained personalised guidance regarding topics of conversation, reassurance techniques and approaches to help reduce anxiety and distress. However, observations and a review of the person’s records showed these personalised approaches were not consistently used when the person experienced periods of distress.

Nutritional assessments identified 4 people preferred to drink from a regular cup; however, they were routinely provided drinks in a spouted beaker. A staff member told us this helped to prevent spillages.

The lack of a dedicated activities team since October 2025 reduced opportunities for people to participate in meaningful activities and social engagement to meet their individual needs and avoid social isolation. During our 3 days of site visits, we did not observe any organised or meaningful activities being offered to people. Staff were frequently observed sitting or standing in communal areas away from people and did not consistently engage them in conversation, interaction or stimulation.

People were not supported to maintain control over their daily lives or exercise choice in the way care and support was delivered. Care practices did not always promote autonomy, and there was limited evidence people were routinely enabled to make informed choices about aspects of their care, treatment and daily routines. For example, people were not always given meaningful choice about meals, daily routines or how support was provided. Mealtimes were largely determined by operational arrangements and kitchen staffing patterns rather than individual preferences, and there was no evidence people had been consulted regarding preferred mealtimes.

Some care practices reflected routine approaches rather than personalised support. Drinks on one unit were routinely provided in spouted beakers despite individual assessments identifying alternative preferences.

Records did not consistently evidence consultation with people or their representatives regarding the management of risks, the use of restrictions, or the recording of conversations through audio-enabled CCTV systems.

Opportunities for people to exercise choice and maintain independence through social engagement and meaningful occupation were limited.

People's immediate needs were not recognised and responded to promptly. For example, observations, records and staff feedback identified occasions where people experienced delays in receiving support, assistance or reassurance when needed, which increased the risk of unmet needs and avoidable distress.

We observed call bells ringing continuously for periods of up to 20 minutes without response. In addition, communal areas occupied by people assessed as being at risk of falls were left unsupervised for periods of up to 15 minutes.

Staff were not always available to respond effectively to people's needs. We observed a member of staff providing personal care to one person whilst being alone and responsible for several other people on the unit.

People experiencing emotional distress did not always receive support reflective of their immediate needs. A person experienced repeated periods of distress lasting between 45 and 60 minutes and did not receive the appropriate reassurance and support during these times.

The provider and registered manager did not promote a culture where staff felt supported, valued and enabled to provide high-quality care. For example, staff feedback and observations identified workforce pressures which impacted on staff wellbeing and their ability to deliver person-centred care. Staff described feeling rushed, under pressure and unable to spend meaningful time with people because of workload demands, staffing pressures and the need to prioritise tasks. Staff reported high use of agency staff, frequent movement of staff between units and late allocation of shifts affected team stability and increased pressure on permanent staff to provide direction and support to staff who weren’t familiar with people.

Communication systems did not always support staff to carry out their roles effectively. Staff reported inconsistent handover arrangements and concerns important information about people's needs, risks and care requirements was not always shared effectively.

The provider's use of audio-enabled CCTV had an impact on staff wellbeing. Staff told us they were reluctant to speak openly within the workplace because they believed conversations were being recorded and monitored. Some staff described feeling uncomfortable discussing concerns or seeking support from colleagues.