Brisegene Care Ltd received an overall rating of Requires Improvement at its first inspection, with breaches of Regulation 17 identified due to ineffective governance systems, incomplete PRN medicine protocols, and insufficient risk assessment documentation. Strengths were noted in personalised, compassionate care delivery and effective partnership working with external agencies.
Concerns (5)
critical
Governance
: “the registered person had not operated an effective system to enable them to assess, monitor and improve the quality and safety of the service provided. Regulation 17 (1, 2,)”
moderateMedication management: “the protocol did not include information such as how long the medicine can be used for or how the person would communicate the medicine is required.”
moderateCare planning: “one person's care plan stated the person was at risk of developing pressure sores, however, did not include action to take if a pressure sore developed.”
moderateRecord keeping: “the audits did not document if there had been any areas of improvement identified or if any changes made.”
minorStaff training: “did not include training in relation to supporting people with a learning disability and autistic people or oral care.”
Strengths
· Registered manager understood safeguarding responsibilities and knew how and when to raise concerns with the local authority.
· Care plans were personalised, written from the person's perspective, and created in partnership with people and their relatives.
· Relatives reported staff treated people with compassion, kindness, dignity and respect, going above and beyond their role.
· Good communication with other agencies including health care professionals, with advice and care changes updated in care plans.
· People's communication needs were assessed and recorded in care plans to guide staff support.
Quality-Statement breakdown (21)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and management; Learning lessons when things go wrongRequires improvement
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Staffing and recruitmentGood
safe: Preventing and controlling infectionGood
effective: Staff support: induction, training, skills and experienceGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Engaging and involving people using the service, the public and staff; Continuous learning and improving careRequires improvement