Brun Lea Care

“Widespread issues were identified in relation to care planning, risk assessment, medicines management, Mental Capacity Act (2005) documentation and record keeping. Care plans were often incomplete, out of date or contained conflicting information, resulting in insufficient guidance for staff to deliver safe, consistent and person-centred care. Risks associated with pressure area care, moving and handling, nutrition, hydration and deteriorating health needs were not always appropriately assessed, reviewed or managed.”

“Medicines management required significant improvement. Concerns were identified in relation to medicines recording, PRN protocols, stock control, covert medicines administration, storage arrangements and auditing processes. Although the provider had recognised medicines management as an area requiring improvement and had begun implementing changes, these actions had not yet resulted in consistently safe practice.”

“Governance systems were not effective in identifying, monitoring and addressing concerns. The inspection identified issues across multiple areas of the service which should have been recognised and addressed through routine oversight and quality assurance processes. Records were not consistently accurate, complete or contemporaneous, reducing assurance that people's needs were being safely managed and reviewed.”

“There were examples of positive practice. Staff demonstrated caring and respectful interactions with people and showed a good understanding of individuals' preferences and routines. People appeared comfortable and relaxed in the presence of staff, and there was evidence of involvement from a range of healthcare professionals to support people's health and wellbeing. Leaders had recognised a number of concerns within the service and had begun implementing improvement plans, including seeking external support, reviewing governance arrangements and introducing revised auditing processes.”

“However, these improvements were not yet embedded and had not sufficiently addressed the concerns identified during the inspection. As a result, there was insufficient assurance that people consistently received safe, effective and person-centred care, or that governance systems were operating effectively to ensure the quality and safety of the service.”

“In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.”