Brushwood House

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 people were protected from abuse and avoidable harm.

This is the first assessment for this service under the new provider. This key question has been rated Inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in breach of legal regulation in relation to people’s safe care and treatment, medicines, staffing and safeguarding.

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 have a proactive and positive culture of safety based on openness, learning and continuous improvement. For example, our review of safeguarding records identified 52 safeguarding concerns between January and July 2026; however, the outcomes, recommendations and lessons learnt section had not been completed for 50 of the 52 concerns. As a result, there was no evidence to show safeguarding incidents had been effectively reviewed, learning had been identified, or actions had been implemented to reduce the risk of recurrence.

Whilst incidents and accidents were generally recorded and immediate actions taken, records rarely evidenced investigation, root cause analysis, identification of lessons learnt, or evaluation of the effectiveness of actions taken. There was limited evidence incidents were analysed to identify trends, themes or opportunities for service-wide learning. We identified recurring themes across incident records, including repeated falls, medication errors, wound care omissions, equipment and environmental concerns, and incidents involving agitation and distress affecting multiple people. Despite the frequency of these incidents, records focused primarily on immediate responses and did not consistently show analysis of contributory factors, review of preventive measures, or evidence learning had been shared with staff and embedded into practice to prevent or minimise reoccurrence.

The provider and registered manager did not work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. For example, staff did not have access to accurate information to support safe care delivery. Care records contained contradictory information relating to dietary requirements, moving and handling needs, staffing requirements, continence care and decision-making arrangements.

Choking risks for people receiving modified diets had not always been appropriately assessed and one person had repeated know symptoms recognised as potential side effects of a prescribed medication without evidence of timely clinical investigation. Another person experienced repeated periods of 5 to 6 days without opening their bowels, however, escalation processes were not consistently followed.

Repositioning records for one person contained several significant gaps despite care plans requiring repositioning every 2 to 3 hours, additionally, records for another person contained missing and unclear information regarding repositioning interventions. We also identified one person had been administered covert medication which was not consistent with the agreed covert medication protocol.

Records identified concerns in communication and transfer of information between services. This included failures in implementing nil-by-mouth instructions, medication discrepancies following hospital discharge and delays in acting upon clinical advice.

People were not protected from abuse, neglect and improper treatment. For example, the provider could not demonstrate all staff had received safeguarding training appropriate to their role. Training records showed 21 of the 74 staff listed had not completed mandatory safeguarding and protection of adults training.

Safeguarding records showed recurring themes of neglect, omissions of care, unsafe clinical practice and failures to follow care plans. A person received covert medication (medicines hidden in food or drink) without an appropriate legal framework, another person was repeatedly offered oral fluids despite being assessed as nil by mouth, and another person developed a pressure wound where repositioning requirements had not been consistently followed.

Audio-enabled CCTV capable of recording conversations involving people, family members, visitors and staff was in operation within communal areas of the home. No safeguards had been implemented to protect people from inappropriate surveillance and breaches of privacy.

The provider and registered manager did not ensure risks to people's health, safety and welfare were consistently assessed, monitored and managed. For example, risks relating to nutrition, choking, skin integrity, falls, medicines and clinical deterioration were not always effectively managed. Choking risks had not been appropriately assessed for people requiring modified diets, and dietary records were inconsistent. A person was served food not prepared in accordance with their assessed dietary requirements, increasing the risk of choking.

Clinical risks were not always monitored or escalated appropriately. One-person experienced repeated symptoms whilst prescribed medication associated with an increased risk of bleeding; however, records did not demonstrate timely clinical investigation or escalation. There was no documented risk assessment to support the management of these known medication-related risks.

Risks associated with skin integrity were not consistently managed. A person's repositioning records contained gaps of more than 4 and 6 hours despite their skin risk management plan requiring repositioning every 2 to 3 hours to reduce the risk of skin damage.

The provider and registered manager did not consistently identify and manage risks within the care environment or ensure equipment, facilities and technology supported the delivery of safe care. For example, we observed hazards which exposed people to avoidable risks. Keypad codes for linen and sluice rooms were displayed next to door locks across all five units, providing unrestricted access to potentially hazardous areas and equipment. The codes were immediately removed from doors after we raised our concerns with the registered manager.

Safeguarding records identified incidents involving broken bed rails, faulty bed controls and failures to ensure equipment was used safely.

Managers daily environmental walkarounds were inconsistent and were not effective in identifying or addressing environmental risks. The concerns identified during our assessment, had not been identified through daily checks and monitoring processes.

The provider and registered manager did not ensure there were enough suitably qualified, skilled and experienced staff to meet people's needs safely and consistently. For example, staff records, observations and feedback identified a high reliance on agency staff across all units, which reduced continuity of care and limited staff knowledge of people's individual needs, preferences and risks.

Agency staff told us they had not read care plans, did not have access to the electronic care recording system and relied on permanent staff to obtain information and complete documentation. We observed agency staff who were unable to identify the names of people they were supporting and who lacked knowledge of people's care needs and preferences.

Communal areas occupied by people at risk of falls were left unsupervised for periods of up to 15 minutes and call bells were observed ringing for up to 20 minutes without response. On one occasion, a person assessed as being at high risk of falls attempted to stand independently while no staff were present, requiring intervention from a CQC inspector to prevent potential harm. Staff reported frequent movement between units, late allocations and inconsistent handovers, resulting in poor communication and reduced continuity of care.

Training records showed significant gaps in mandatory training, including safeguarding, mental capacity, care planning, nutrition and hydration, dysphagia, infection prevention and control, moving and handling and medicines-related subjects. A substantial amount of training was completed during and immediately following the assessment period, indicating a reactive response to training needs. The provider and registered manager were unable to provide evidence of a consistent formal supervision programme to support staff competence, performance and professional development.

Staff described feeling rushed, under pressure and unable to spend meaningful time with people due to workload and staffing pressures. They reported occasions where only one permanent member of staff was working alongside multiple agency staff who required ongoing support and direction.

The provider and registered manager did not effectively assess, monitor or manage the risk of infection, or take sufficient action to prevent and control the spread of infection. For example, we observed poor standards of environmental cleanliness throughout the home, including dirty baths, toilets, falls mat, kitchen equipment, windowsills and furnishings. Kitchenettes on three units were visibly unclean, with accumulations of dirt, staining and food debris on appliances, walls, kickboards, bins and cleaning equipment.

Staff reported the dishwasher on a unit had been out of service for approximately 3 weeks. We observed stagnant water and a foul odour within the dishwasher. Refrigerators were unclean and containers of juice were stored directly on the kitchen floor, increasing the risk of contamination. The kitchenettes were cleaned and the dishwasher removed after we raised our concerns with the registered manager.

Staff did not always follow safe infection prevention and control practices. We observed a member of staff placing soiled bedding directly onto a person's bedroom floor, and 2 members of staff leaving people's bedrooms while still wearing used personal protective equipment (PPE). We observed modified meals being served with printed dietary labels placed directly onto the plate next to food.

In addition, a person was observed mobilising independently with a leaking foot dressing in direct contact with the floor, increasing the risk of environmental contamination and infection. Following concerns we raised, staff provided the person with a protective foot covering to reduce the risk of contamination.

The provider and registered manager did not make sure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved inplanning. For example, medicines were stored in locked rooms; however, different people's medicines were sometimes stored together, increasing the risk of mis selection. Stock counts of medicines were not recorded consistently or accurately so we were not assured medicines were being administered as prescribed or discrepancies would be identified promptly.

Medicines administration records (MARs) were not always complete or correct. We saw one person had not completed a treatment course putting them at risk of treatment resistance. Medicines administered covertly (hidden in food or drink) were not always given safely or in line with guidance.

Care plans and clinical records did not consistently provide accurate or sufficient information to support people's health needs. Conflicting information was present in some records, instructions were not always followed, and protocols for 'when required' medicines were not always person-centred or detailed enough to support safe administration. Thisincreased the risk of people receiving inconsistent or unsafe care.

Guidance relating to percutaneous endoscopic gastrostomy (PEG) management was inconsistent, equipment maintenance instructions were not always followed, and records did not demonstrate all relevant staff were competent in providing this care. Dietetic recommendations and fluid intake targets were not consistently met, placing people at risk of poor nutrition and hydration. Training records provided did not give assurance all staff involved in administration of medicines had completed the relevant training. Risks to staff associated with handling hazardous medicines had not been assessed.

Although medicines audits were undertaken, action plans were not always completed and audit processes failed to identify or address all the concerns found during inspection.