Brushwood House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in breach of legal regulation in relation to governance and leadership.

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 demonstrate a positive, open and learning-focused culture that promoted high-quality care. For example, safeguarding concerns, staff feedback and governance reviews identified a disconnect between the provider's stated commitment to quality and the experiences of people and staff. Concerns identified across the home were widespread, affected multiple people and continued over a prolonged period, indicating expectations regarding quality, safety and accountability were not consistently understood or embedded in practice.

Staff described working under significant pressure due to staffing shortages, high use of agency staff, frequent movement of staff between units and increasing workloads. Staff reported feeling rushed and unable to spend meaningful time with people. They reported concerns regarding continuity of care and described situations where permanent staff were required to continually direct agency staff due to their limited knowledge of people's needs and preferences.

The operation of audio-enabled CCTV systems further raised concerns regarding organisational culture and transparency.

Care records reviewed contained copy-and-paste errors, conflicting information and information which did not reflect people's current needs. Monitoring records failed to accurately reflect assessed care needs.

The provider and registered manager were unable to demonstrate effective oversight of the service or ensure risks were identified and addressed in a timely way. For example, significant concerns relating to safeguarding, care planning, medicines management, nutrition, staffing and governance had not been identified or effectively managed through provider systems.

Managers could not demonstrate incidents had been reviewed, learning identified or improvements implemented to reduce the risk of recurrence.

Training records showed gaps in mandatory training, with many courses only completed during or after the assessment period, indicating poor oversight of staff development.

Staff, family members and visiting professionals consistently described the registered manager as having limited visibility within the home. Feedback indicated there were few opportunities for meaningful engagement with managers, and people did not always feel listened to when raising concerns or sharing feedback.

In addition, the registered manager was unable to clearly explain governance and accountability arrangements for the Treatment of Disease, Disorder and Injury (TDDI) regulated activity or provide assurance regarding oversight responsibilities. Governance failings were widespread and reduced confidence in managers ability to effectively manage the home and drive improvement.

The provider and registered manager did not foster a positive culture where people felt able to speak up and be confident their voice would be heard. For example, staff provided mixed feedback about leadership visibility and engagement, with several describing limited opportunities to raise concerns, contribute to service development or receive feedback about issues they had reported.

Staff told us they felt uncomfortable speaking openly in some areas of the home due to being monitored through the CCTV system.

The provider and registered manager could not demonstrate equality, diversity and inclusion principles were embedded within the culture of the service or workforce development programme. For example, staff feedback highlighted limited visibility and engagement from managers, reducing opportunities for meaningful involvement, discussion and feedback.

Training records showed only 1 of the 74 staff listed had completed Equality, Diversity and Inclusion (EDI) training. This reduced assurance staff had the knowledge and understanding required to recognise, respect and respond to people's individual identities, preferences and diverse needs.

We identified examples where people's individual preferences were not always respected in practice. This included a person whose expressed preference regarding the gender of staff providing intimate care was not consistently upheld. Staff were observed using task-focused language when referring to people, which did not always promote individuality, dignity, respect or inclusion.

The provider and registered manager did not operate effective governance systems to assess, monitor and improve the quality and safety of the service. For example, numerous concerns identified, including failures in care planning, risk management, safeguarding, medicines management, nutrition, infection prevention and control, staffing and record keeping, had not been identified or addressed through the provider's own quality assurance processes. Significant concerns previously identified by the local authority during quality monitoring visits remained evident at the time of this assessment, demonstrating a lack of sustained improvement.

Governance systems were ineffective in ensuring accurate and reliable records. Care plans, risk assessments and monitoring records were frequently incomplete, contradictory or inconsistent with observed practice. Provider audits had failed to identify inaccuracies in care records, gaps in monitoring, poor oversight of safeguarding concerns and recurring themes arising from incidents and accidents.

The registered manager did not demonstrate effective oversight of safeguarding and organisational learning. As a result, incidents had not been fully investigated, learning had not been identified, or improvements implemented to reduce the risk of recurrence.

The registered manager lacked effective oversight of workforce training and competence. Training records showed significant variation in compliance across the workforce, with substantial gaps in mandatory training and a notable volume of training completed during and immediately following the assessment period. There was no robust system in place to monitor training compliance or assure staff competency in key areas of practice.

The registered manager was unable to clearly explain oversight responsibilities or governance arrangements between the care provider and the nursing provider and told us they had not seen the contractual arrangement.

The provider and registered manager could not demonstrate effective partnership working and collaborative relationships to support the delivery of safe, high-quality care. For example, whilst there was evidence of involvement from external healthcare professionals, records identified occasions where professional advice, treatment changes and clinical recommendations were not always implemented, communicated or embedded into care delivery in a timely manner.

Feedback received indicated limited visibility and engagement from managers with staff, family members and external stakeholders.

The provider and registered manager did not demonstrate a culture of continuous learning, improvement and innovation. Systems and processes were not effective in identifying, analysing and learning from incidents, safeguarding concerns and areas of poor practice. For example, incidents and safeguarding concerns recorded, contained limited evidence of investigation, root cause of incidents, trend monitoring or evaluation of whether actions taken had been effective in reducing future risk.

Governance systems did not demonstrate an ability to identify concerns proactively or drive sustained improvement. Significant issues identified during local authority quality monitoring visits remained evident during the assessment. Additionally, a substantial amount of staff training was completed during and immediately following the assessment period, indicating a reactive response to concerns rather than a planned and continuous approach to improvement.

Complaints management systems were ineffective. The complaints tracker recorded only 4 complaints; review of other records identified at least 14 additional complaints not recorded on the complaint’s tracker. These complaints were identified through feedback from family members and review of incident records. Furthermore, the complaints tracker did not provide assurance complaints were investigated, reviewed and used to drive improvement. Although actions were recorded and complaints were closed, documentation was not consistently maintained to capture investigation findings, complaint outcomes, lessons learned, corrective actions to prevent recurrence, complainant satisfaction, or evidence of management review.