Bush Rest Home

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• 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 that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (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’s systems to analyse incidents and share learning did not consistently ensure sufficient action was taken when themes were identified. The provider analysed incidents using a system to identify themes and these were being shared with staff, however there was not always action taken to consider the theme and what may assist in reducing this. In August 2025 there were 7 falls noted as taking place in bedrooms. Records did not show if there had been consideration of any actions which may be needed to prevent the theme of reoccurring falls in bedrooms. This meant opportunities were missed to act on this safety theme at the service. However, individual risk assessments and care plans had been reviewed for each person who had experienced a fall, and other themes and trends had been addressed. For example, staff were continually present in the lounge area, to reduce the risk of people falling. The manager told us they would review the system in place and ensure where themes were identified there was clear action taken to review and address these and minimise continued risk.

The provider did not always ensure the systems in place were used effectively to maintain safe systems of care and support. The provider had systems in place to record incidents of distressed behaviour. However, there was no system in place to analyse these incidents and ensure any learning about triggers or what helped to calm the person when they were distressed. This meant people may be exposed to continued periods of distress. The manager told us they were working with other professionals to review these records but would also introduce a system to analyse these and ensure learning informed a review of risk assessments and care plans going forward. Improvements had been made to care plans and risk assessments following the last inspection where people experienced distressed behaviours. Other systems were in place to ensure people had their needs met and risks managed. These included weight monitoring processes to ensure people maintained a healthy weight and actions were taken to address any concerns.

The provider did not always ensure concerns about safety were shared with the appropriate body for investigation. Where people had unwitnessed falls and an injury had been sustained, we could see risk assessments and care plans were updated. However, there was not always a reference to if a safeguarding referral had been raised. The provider told us the safeguarding team had told them not to send safeguarding referrals in these circumstances; however, they would ensure any unwitnessed injuries were reported for consideration and investigation going forward. Other incidents had been reported to the appropriate body. Staff understood how to protect people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had received training in recognising abuse and understood how to report any concerns. People told us they felt safe living at the home and relatives confirmed they felt people were safely supported. A person told us, “I definitely feel safe. Everyone here makes me feel safe.” A relative told us, “[Person’s name] is safe because they have a Deprivation of Liberty Safeguard (DoLS) in place, so they can’t go out alone and are as safe as they can be.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the provider had a system in place to ensure applications were submitted to the authorising body as required and tracking was in place to ensure any conditions were met and renewals were requested.

The providers systems did not always ensure information about risks to people’s safety was included in people’s care plans. Risk assessments were completed when risks were identified for people, and these were reviewed monthly. However, the care plans had a summary section which included information to guide staff about key risks, we found this was not always accurate and up to date with all the risks identified for people. For example, 1 person had become at high risk of falls, and this was not included in the summary of key risks. In another example, 1 person had some distressed behaviours and the risks associated with this were also not included in the summary care plan. This meant new or temporary staff may not be aware of all the key risks for these people as key information was not always consistently accessible. However, staff we spoke with demonstrated they understood risks to people and could describe how they would support people to maintain their safety. For example, they knew how to safely transfer people using equipment, maintain people’s nutritional intake and support people to maintain skin integrity. The manager told us they would update the records to ensure all information about risks was included in the summary care plan. We will check this at the next inspection. People told us they were safely supported. A person told us, “I couldn’t walk without my frame and normally I have a member of staff to walk with me to make sure I don’t fall. I don’t think I have ever fallen so I’m safe.” A relative told us, “She is hoisted as she can’t weight bear. I’ve seen them hoist her. They know how to do it. The physio has been in to check her as well. They know what they are doing. Others are hoisted so they already had a hoist.”

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.The provider had systems in place to promote safe environments; however, staff did not consistently ensure they followed the guidance in place to maintain a safe environment. We saw a door with a key coded lock and a sign to say it must be locked at all times was left open. The doorway gave access to a room which had chemicals stored in and a steep stone staircase which led to the basement of the home. This meant people could access this area which placed them at risk of harm. The manager told us the door should be locked at all times, and they would remind staff. Other environmental safety processes were effective. For example, there was a system in place to report any repairs, and these were actioned straight away. Checks were carried out on the building and equipment to ensure safety.

The provider did not always make sure there were enough staff available to support people safely. People and their relatives told us there were times when there were not enough staff to support people. A person told us, “Some days the staff are in a rush because they are short staffed.” Another person told us, “I do ring the buzzer, I wait a long time for the staff to get me up. I do think they could do with more staff on a morning.” A relative told us, “There’s not enough staff. At times there’s no staff in the lounge.” Another relative told us, “There’s no staff around is there? I don’t think there’s enough staff to cover everywhere. I do know it takes them ages to answer the front door when I visit. They are always so busy.” During lunchtime some people chose to stay in the lounge for their meal, there were no staff in the lounge area to offer support and encouragement for people to eat. This meant 2 people did not eat their meal and it was left to go cold. Staff eventually came in and offered people a pudding instead, which we saw people eat with staff encouragement.. Staff told us there were times when it was very busy and they always tried to make sure people had the support they needed. However, because lots of people needed 2 staff to support them, it sometimes meant people had to wait. The manager told us there was a dependency tool in place and this was reviewed monthly or when new people came into the home. They told us they would increase staffing numbers by 1 member of staff during the day and review the dependency tool. We will check this at our next inspection. Staff were recruited safely and received an induction into their role. We saw staff had regular updates to their training and this was monitored by the manager. Staff told us they received regular supervision and could discuss their role during these sessions to receive the support they needed. Documents we saw supported what we were told.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People and relatives told us the home was clean, and staff were observed using protective equipment. A relative told us, “Her room is always clean. We’ve not had any problems at all.” Staff told us they had received training in infection prevention control, records supported this. The manager understood how to report any incidents of concern and undertook a regular audit of infection control procedures. We saw staff used protective equipment through the day of the inspection. The provider had an infection prevention control policy which guided staff on how to ensure safe practice was followed.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines as prescribed. A person told us, “The staff give me my medicine every day.” Staff received training and had their competency checked to ensure they were able to follow the medicines administration policy safely. Checks were in place to ensure peoples medicines were stored safely, this included checking the room temperature and ensuring stock was rotated. Medicines guidance was in place for staff which showed how they should administer medicines, including medicines prescribed to be taken ‘as required’. Medicines records were accurately completed and included body maps for administering topical medicines. Stock checks were in place to ensure people had enough supply of their medicines.