Brushwood House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence the provider and registered manager met people’s needs.

This is the first assessment for this service under the new provider. This key question has been rated Inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The provider was in breach of legal regulation in relation to person centred care.

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 ensure care and support was organised and delivered around people's individual needs, preferences, wishes and circumstances. For example, care was often delivered according to routines, staffing arrangements and operational pressures rather than people’s needs. Inaccurate and contradictory information within care plans meant they were not reflective of people's current needs and preferences.

The provider and registered manager did not always respond appropriately to changes in people's circumstances or ensure care plans reflected those changes. Records contained examples of information not being updated following changes to care requirements, clinical advice and nutritional interventions.

People's social and emotional wellbeing was not always supported through personalised approaches to care. Staff described workload pressures which limited the time available to spend with people beyond essential care tasks.

The provider's reliance on agency staff further impacted the delivery of person-centred care. Agency staff reported limited access to care records and insufficient knowledge of the people they supported.

The provider and registered manager did not ensure people experienced coordinated, continuous and integrated care. Records, safeguarding concerns and staff feedback demonstrated weaknesses in communication, information sharing and the implementation of care and treatment decisions across teams and services. For example, there were examples where important healthcare information had not been effectively communicated or implemented. Safeguarding records relating to a person identified as needing dietetic advice had not been passed to staff, raising concerns regarding communication between professionals and care staff, and the implementation of specialist recommendations.

Care was not always coordinated effectively following changes in treatment or clinical advice. A person received incorrect insulin doses over an extended period because medical advice was not promptly documented, nor was it reflected in care records or implemented in practice.

There were examples where people experienced disruptions in continuity of treatment. Safeguarding records identified a person was not administered prescribed medication because treatment arrangements and medication management processes were not effectively coordinated.

Staff reported there was no consistent handover process regarding changes to people's needs, dietary requirements or care instructions. In addition, agency staff reported they did not have access to the electronic care record system and relied upon permanent staff to obtain information about the people they were supporting.

The provider and registered manager did not consistently ensure accurate, complete and accessible information was available to support the delivery of safe and effective care. For example, care records were frequently inaccurate, contradictory or incomplete, therefore staff did not have clear and reliable information to guide care delivery.

Records did not consistently support effective communication between staff, teams and external professionals. We identified examples where important information relating to people's care, treatment and changing needs had not been accurately documented or clearly communicated, resulting in inconsistent care and delays in implementing recommendations from healthcare professionals.

Daily care records were not always signed by the member of staff who had provided the care reducing accountability and limiting assurance regarding the accuracy of records.

Review of complaints, incident and safeguarding records identified gaps and inconsistencies in recording, limiting assurance important information was consistently captured, reviewed and used to support people safely.

The provider and registered manager did not demonstrate people, relatives and representatives were listened to, involved in decisions about care, or their feedback was used to improve the service. For example, feedback indicated variable experiences of involvement, with family members reporting they were not routinely involved in care planning or reviews.

Complaints and concerns were not consistently investigated, monitored or used to identify learning and service improvements. Complaint records lacked evidence of investigation outcomes, lessons learnt, trend analysis and management oversight, reducing assurance people's views and experiences were acted upon effectively.

The provider and registered manager did not ensure people had equitable access to safe, timely and appropriate care and support. For example, systems and processes did not support consistent access to information, treatment, clinical interventions and personalised care, resulting in some people experiencing delays, omissions or inconsistencies in the care they received.

People did not always receive equitable access to prescribed medicines and treatments. Safeguarding records identified occasions where prescribed medication was unavailable due to medication management and ordering failures. This affected 8 people resulting in prescribed, ‘as required’ medicines not being available when required.

Some people experienced delays in accessing appropriate healthcare interventions. A person did not receive prescribed medicines between 30 March and 23 April 2026. Records identified failures in medicine management processes which resulted in the prolonged omission of treatment.

Safeguarding records identified examples where advice from healthcare professionals was not implemented promptly, including delays in responding to medication changes and failures to act on specialist recommendations.

The provider and registered manager did not ensure people experienced equitable outcomes or received care that achieved consistent standards across the service. For example, care record reviews and safeguarding concerns identified variation in the quality-of-care people received, with some people experiencing avoidable deterioration, omissions of care and inconsistent implementation of assessed needs.

People with similar levels of dependency and risk were not always receiving consistent standards of care. We observed excessively overgrown fingernails for several people, despite records indicating daily nail care checks had been completed. In some cases, fingernails were observed digging into the persons palms, posing a risk of skin damage and discomfort.

Outcomes for people at risk of malnutrition, pressure damage and deterioration were not consistently monitored or improved. A person experienced significant weight loss over a six-month period and remained at high nutritional risk despite ongoing interventions, while another person had a consistently low body mass index (BMI) and records demonstrated poor nutritional intake on multiple occasions. In addition, a person developed a pressure wound where repositioning requirements had not been consistently followed.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life. For example, end-of-life care plans for people lacked sufficient detail to guide staff in providing person-centred care when people reached the end stages of their life. Whilst they recorded the person had a DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) in place and wished to be kept comfortable, there was no evidence their end-of-life wishes had been discussed with the person or their representative.