Brushwood House

We undertook this assessment following concerns we received about people’s safety, and leadership and governance of the service. We found the provider 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 governance.

This was the first assessment of this service since it was registered under the current provider in August 2024. A comprehensive assessment was undertaken, covering all 34 quality statements across the five key questions: Safe, Effective, Caring, Responsive, and Well-led.

We identified widespread and systemic concerns affecting the quality, safety and governance of the service. Significant failings were found in relation to person-centred care, dignity and respect, consent, safe care and treatment, medicines, safeguarding, nutrition and hydration, staffing and governance. These concerns were not isolated incidents and reflected weaknesses in leadership, oversight and quality assurance arrangements.

Governance systems were ineffective in identifying, monitoring and addressing risks. Care records were often inaccurate, incomplete or contradictory. Safeguarding systems did not demonstrate effective learning, and quality assurance processes failed to identify many of the concerns we found. Opportunities to learn from incidents, complaints and safeguarding concerns were frequently missed.

Risks relating to medicines, nutrition, hydration, choking, falls, skin integrity, infection prevention and control, and clinical deterioration were not consistently assessed or managed. There was a lack of effective oversight of safeguarding concerns, and lessons learned were not used to improve practice.

We identified concerns regarding privacy, dignity and confidentiality. Sensitive information was not always appropriately protected, and governance arrangements relating to audio recording through CCTV systems were inadequate.

Staffing and workforce oversight were insufficient. Training records showed significant gaps in mandatory training and evidence substantial amounts of training were completed during and after our assessment period, reducing assurance staff were appropriately trained prior to our assessment.

In instances where CQC has decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded. This service is being placed in special measures. The purpose of special measures is to ensure services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.