Brushwood House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this service under the new provider. This key question has been rated Inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The provider was in breach of legal regulation in relation to people’s need for consent

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.

The provider and registered manager did not assess, record and review people's needs to ensure care and treatment was planned and delivered effectively. For example, information contained within care records was frequently inaccurate, contradictory and lacked sufficient detail to provide assurance assessments reflected people's current needs and circumstances. We observed conflicting information in multiple peoples care records regarding continence care, moving and handling requirements, staffing support needs, dietary requirements and decision-making arrangements.

Dietary assessments and care plans for 3 people assessed as being at risk of choking contained contradictory information regarding their dietary needs and food textures. One person's records stated they required both IDDSI (International Dysphagia Diet Standardisation Initiative) Level 5 minced and moist food and Level 6 soft and bite-sized food in different parts of their records. Another person was recorded as requiring Level 5, Level 6 and Level 7 (regular food) across different assessments and care plans.

The provider and registered manager did not ensure care and treatment were delivered in accordance with current evidence, professional guidance or assessed clinical needs placing people at risk of not receiving safe and effective care. For example, our review of people’s care records and observations identified occasions where care provided did not reflect documented assessments, specialist recommendations or recognised care standards. People did not always receive food and drink in accordance with their assessed swallowing and dietary requirements. A person was served a pureed meals despite their care records identifying a requirement for an IDDSI Level 6 soft and bite-sized diet. In addition, records for 2 other people contained conflicting dietary information, making it unclear which food texture recommendations staff should follow.

Records did not provide sufficient assurance Speech and Language Therapy (SALT) recommendations had been appropriately considered and incorporated into care planning for people receiving modified diets. Concerns were identified regarding the administration of drinks and nutritional supplements by syringe to a person, despite identified choking and aspiration risks and without evidence of a supporting assessment, care plan or clinical instruction.

Clinical monitoring and treatment interventions were not always implemented in line with people’s assessed needs and recognised good practice. A persons care plan required staff to monitor, document and escalate deterioration in skin integrity. Despite records showing observations of redness, blisters and skin deterioration over several days, there was no evidence concerns had been escalated to a GP in accordance with the person’s care plan. Similarly, repeated episodes of black stools recorded for 2 people were not consistently investigated or escalated despite the potential significance of these symptoms.

A person’s care plan contained detailed guidance regarding reassurance techniques and approaches to managing anxiety and distress; however, records contained limited evidence these interventions had been consistently implemented during repeated periods of distress.

The provider and registered manager did not ensure effective communication, coordination and joint working between staff, teams and external professionals. For example, communication systems were not reliable and there was insufficient assurance important information about people's care, treatment and changing needs was consistently shared, understood and acted upon. Staff described inconsistent handover arrangements and reported there was no robust process to ensure changes to people's needs, dietary requirements, risks and care instructions were consistently communicated between shifts.

Communication failures resulted in omissions in medicine administration and delays in acting on clinical advice received from healthcare professionals.

Safeguarding records identified multiple concerns relating to medication discrepancies following hospital discharge and failures to ensure important clinical information was accurately transferred into care records and medication administration systems.

The provider and registered manager did not support people to maintain and improve their health and wellbeing through timely monitoring, intervention and access to healthcare services. For example, records did not always evidence changes in people's health were recognised promptly or appropriate action was taken to prevent deterioration. Healthcare concerns were not always responded to in a timely manner.

A person who was assessed as being at extremely high nutritional risk, had multiple occasions where meals were declined or intake was poor, and records showed periods where no meals had been documented following discharge from hospital. Another person had repeated recordings of very low fluid intake despite significant nutritional concerns and ongoing weight loss.

A person experienced recurrent skin concerns, including redness, blisters and deterioration of a scalp condition. Although these concerns had been documented, records did not evidence escalation to a GP in accordance with the person's care plan.

Opportunities to support people to remain active and engaged were limited. Staff reported there had been no dedicated activities staff since October 2025, reducing opportunities for structured activity, social engagement and meaningful occupation. Staff further reported workload pressures limited the time available to support people beyond essential care tasks.

The provider and registered manager did not monitor, evaluate and improve outcomes for people. Systems used to monitor health, wellbeing and care delivery were not accurate, effective or reliably used to identify deterioration, evaluate interventions or drive improvements in care. For example, records frequently contained inconsistencies, inaccuracies and gaps, reducing assurance outcomes were being effectively monitored and acted upon.

Monitoring records did not always reflect people's actual experiences or care received. A person’s food monitoring records stated breakfast had been consumed despite inspectors observing the meal untouched at the bedside. Similarly, fluid monitoring records for another person recorded drinks as fully consumed when our observations showed some drinks remained untouched or only partially consumed.

A person had two significantly different weights recorded within six minutes of each other with no explanation documented. Another person experienced significant weight loss despite ongoing dietetic involvement and nutritional interventions; however, multidisciplinary reviews repeatedly recorded there were no concerns identified.

Repositioning records contained significant gaps, missing entries and unclear documentation, making it difficult to determine whether pressure-relieving interventions had been completed as required. Skin integrity monitoring records contained omissions and incomplete documentation, limiting oversight of people's changing needs and outcomes.

Records showed daily nail checks had been documented as completed, despite inspectors observing multiple people with unclean and excessively overgrown fingernails and evidence one person had experienced skin damage associated with poor nail care.

The provider and registered manager did not ensure care and treatment was always provided with appropriate consent or in accordance with the Mental Capacity Act 2005. For example, records did not consistently demonstrate decisions affecting people's care, treatment and support had been underpinned by appropriate capacity assessments, consent discussions or clearly documented best-interest decision-making processes. Restrictive interventions were in use without evidence of the required decision-making processes. Records for one person did not contain a completed best-interest decision relating to the use of bed rails, a wheelchair lap strap and a sensor mat. Similarly, two other people who had been assessed as lacking capacity did not have documented best-interest decisions to support the use of restrictive aids.

Records contained inconsistencies relating to people's capacity and decision-making arrangements. In some cases, documentation did not clearly evidence how decisions had been reached, whether the least restrictive options had been considered, or how decisions were reviewed and applied in practice.

There was a lack of assurances appropriate capacity assessments, consent processes or best-interest decisions had been completed in relation to modified diets, dietary restrictions and other aspects of care where people may have lacked capacity to make specific decisions. In addition, there were no records evidencing consent, capacity assessments or best-interest decisions relating to the recording of conversations.