Brun Lea Care

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation as systems and processes were not effective in assessing, monitoring and improving the quality and safety of the service. Widespread concerns identified during the inspection relating to care planning, risk management, medicines management, recruitment processes and record keeping had not been identified or addressed through the provider's governance and oversight systems.

Records were not consistently accurate, complete or reflective of people's current needs, and auditing processes had failed to identify and address a number of the concerns found during the inspection. As a result, there was insufficient assurance that the provider had effective oversight of the service or that risks to people were being consistently identified and managed.

This service scored 61 (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 had a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They understood the challenges and the needs of people and their communities.

The management team had recognised the need for improvement and communicated a clear direction focused on governance, transparency, training and quality assurance. Staff described significant organisational changes and some reported these changes were moving the service in a positive direction.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders demonstrated an awareness of a number of concerns within the service and had begun implementing changes to improve quality and safety. This included seeking support from an external consultant, reviewing quality assurance processes, introducing additional audits and developing plans to implement electronic care records and medication systems.

However, there were widespread concerns relating to care planning, medicines management, risk management, recruitment practices, Mental Capacity Act (2005) documentation and record keeping. Many of these issues had either not been identified through existing oversight systems or had not been addressed effectively despite management being aware of them. This reduced assurance that leaders had sufficient oversight of the service and had taken timely action to ensure people consistently received safe, high-quality care.

Leaders spoke openly about the challenges within the service and demonstrated a willingness to improve. However, the improvements described by management were not embedded and had not consistently translated into improved outcomes for people at the time of inspection.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told inspectors they felt able to raise concerns and challenge practice where required. Examples were provided of staff escalating concerns to managers and requesting additional training.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff reported being treated fairly and described management as supportive. No concerns relating to equality, diversity or inclusion were identified during discussions with staff.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems had not been effective in ensuring the quality and safety of the service. Inspectors identified concerns across multiple areas, including care planning, risk management, medicines management, Mental Capacity Act (2005) documentation, recruitment practices and record keeping. These issues were widespread and demonstrated a lack of effective oversight.

The provider had not ensured records were consistently accurate, complete or reflective of people's current needs. Care plans were often out of date, contained conflicting information or lacked sufficient guidance for staff. Risks relating to pressure care, moving and handling, nutrition and hydration had not always been appropriately assessed, reviewed or managed. The provider's systems had not identified or addressed these concerns in a timely way.

Medicines governance was not effective. Inspectors found concerns relating to medicines storage, recording, PRN protocols, covert medicines administration, stock control and auditing processes. Although medication had already been identified by the provider as an area of concern, improvements had not yet resulted in consistently safe practice.

Quality assurance systems had failed to provide sufficient oversight of staff recruitment and competency. Records reviewed contained gaps in recruitment documentation, outstanding references and incomplete employment histories. In addition, systems for monitoring supervision, competency and staff performance were not sufficiently robust.

Leaders had taken steps to improve the service, including engaging external consultancy support, reviewing audit processes and introducing plans to implement electronic care planning and medication systems. However, these improvements were not yet embedded and inspectors continued to identify significant concerns across the service. As a result, inspectors were not assured that governance arrangements were effective in identifying risks, driving improvement and ensuring people consistently received safe, high-quality care.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider had developed positive working relationships with healthcare professionals, pharmacy services and external consultants. These partnerships were being used to support improvement activity and address identified concerns.

The provider was starting to focus on continuous learning, innovation and improvement across the organisation and local system. However, this had not started to impact and improve the care people received.

The provider had begun implementing electronic care planning and medication systems and was reviewing its auditing arrangements. External consultants had been engaged to undertake mock inspections and provide ongoing support. These actions demonstrated a willingness to improve, although the changes were not yet fully embedded or evidenced through consistently improved outcomes for people.