- Care home
Brun Lea Care
We served 2 warning notices on Brun Lea Care Ltd on 13 August 2026 for failing to meet the regulations relating to safe care and treatment and good governance at Brun Lea Care.
Assessment report published 7 September 2026
Contents
Ratings
Our view of the service
The assessment was completed between 30 June 2026 and 12 August 2026. This assessment was completed due to the age of the rating. The provider was in breach of the legal regulation in relation to the safe care and treatment and good governance.
The inspection identified significant concerns relating to the safety, effectiveness and governance of the service. While staff were generally observed to be kind, caring and knowledgeable about the people they supported, this knowledge was not consistently reflected in care records or supported by effective systems and processes.
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 Care plans were often incomplete, out of date or contained conflicting information, resulting in insufficient guidance for staff to deliver safe, consistent and person-centred care.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.
People's experience of this service
People and their relatives spoke positively about many aspects of life at the service. People appeared comfortable, relaxed and familiar with staff supporting them.
Staff demonstrated a good knowledge of people's individual preferences, routines and personal histories and there were examples of people being offered choice and support to maintain aspects of their independence.
People told us they were able to make decisions about their daily routines, food choices and how they wished to spend their time. One person told us, “I go to bed when I am ready.” Staff interactions were generally observed to be caring, patient and respectful.
While people expressed general satisfaction with their care our assessment found care elements of care did not meet the expected standards. There were concerns that people's experiences were not always supported by effective systems, accurate records and consistent care planning. Care records did not always reflect people's current needs, preferences and risks, meaning there was a reliance on staff knowledge rather than robust care planning to ensure consistent care. People with changing needs, including those experiencing weight loss, declining appetite or increased dependency, were not always subject to timely review or updated care planning.
People told us that staffing levels met their needs. One person said, "There is enough staff and they come quickly." However, care delivery at times appeared task-focused rather than fully person-centred. While staff knew people well, there was limited evidence that care was consistently planned and reviewed around people's individual outcomes, goals and changing needs. Daily records largely focused on the completion of care tasks rather than capturing people's experiences, wellbeing and the impact of the support provided.
People generally had access to healthcare professionals when required and there was evidence of involvement from district nurses, speech and language therapists and other healthcare services. One person told us, “If you are not well [staff] will get the doctor for you.” However, some risks relating to nutrition, hydration, pressure care and moving and handling had not always been fully assessed or managed, which may have impacted people's experience of care and wellbeing.