The Care Quality Commission (CQC) has rated Brushwood House in Liverpool as inadequate and placed it into special measures to protect people following its first inspection in July.
Brushwood House, run by Liverpool City Council is a residential home for people who require personal and nursing care.
CQC carried out the inspection after receiving concerns about people’s safety, and the management of the service.
Inspectors found the home was in breach of regulations in relation to safe care and treatment, medicine management, staffing, dignity and respect, need for consent, person centred care, nutrition and hydration, safeguarding and management of the service.
CQC has rated Brushwood House as inadequate for being safe, effective, caring responsive and well-led.
CQC has also placed the service into special measures which involves close monitoring to ensure people are safe while they make improvements. Special measures also provides a structured timeframe so services understand when they need to make improvements by, and what action CQC will take if this doesn’t happen.
CQC has also begun the process of taking regulatory action to address the concerns which Brushwood House has the right to appeal.
Andrew Peck, CQC’s deputy director for adult social care in the north west, said:
“When we inspected Brushwood House, we found failings in leadership that placed people at risk of avoidable harm. Leaders weren’t managing the service well, meaning people weren’t receiving the safe and person-centred care they deserved.
“For example, we saw call bells ringing for up to 20 minutes without anyone answering, and we found people at risk of falls left alone in communal areas for long periods of time. One person’s care records said they’d eaten their breakfast, but our inspectors found the meal untouched at their bedside.
“We also found that people weren’t always protected from harm. Medicines weren’t always managed safely, including one person who went without their prescribed medication for over three weeks. We also found examples of medication being hidden in food and given without appropriate legal processes in place, as well as another person being offered fluids despite being assessed as being at risk of choking.
“Staffing was a real concern for people living at the home and their families. People told us there weren’t always enough staff, and that they sometimes had to wait a long time for help. Relatives were also concerned that agency staff didn’t always know people’s needs. Inspectors saw this too, with one family member telling us that some agency staff didn’t have a clue what they were doing.
“We were also concerned about people’s privacy and dignity. Audio-enabled CCTV was operating in communal areas without proper safeguards, and staff told us it left them reluctant to speak freely.
“However, some people and their families told us staff were kind and caring, but the home’s systems and processes kept letting people down.
“We’ve told leaders where it must improve, and we’ll continue to monitor the home closely to make sure people are kept safe while those changes happen.”
Inspectors found:
- Staff did not consistently provide food and drinks in the correct texture to meet people’s swallowing needs, despite records identifying some of them at risk of choking.
- Staff did not consistently reposition people as required to prevent painful pressure sores, and care records were incomplete, making it difficult to confirm whether repositioning had taken place.
- Staff did not store people’s medicines separately and securely, sometimes keeping different people’s medicines together, increasing the risk of medication errors.
- Staff did not consistently treat people with dignity and respect, such as referring to someone as ‘a hoist’ or ‘a pureed.’
- Staff did not protect people’s privacy and confidentiality, displaying personal and sensitive medical information openly on bedroom doors and in communal areas.
- Managers did not provide a dedicated activities coordinator for several months, limiting people’s opportunities to take part in meaningful activities and socialise.
- Staff did not consistently engage with people in communal areas, with inspectors observing staff sitting around without speaking to or interacting with them.
However:
- Leaders have informed CQC that they have started to make improvements to address the issues identified during the inspection.