7 December 2023
During a routine inspection
Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.
People's experience of using this service
Risk assessments and risk management plans were not always in place or were not adequate. People's medicines were not always safely managed. There was not a robust safeguarding process in place to keep people safe. Appropriate recruitment checks were not carried out before staff joined the service. There was a system in place to log and investigate accidents and incidents, but these were not analysed, and any learning was not disseminated to staff. Records showed people’s independence was not always promoted.
Staff had not received adequate training. Staff were not always supported through regular supervision. Governance systems were not effective at identifying and reducing risks to people's safety. There was a lack of oversight and effective leadership of the service.
People or their relatives were involved in planning their care and support and their care plans but these were not reviewed regularly. People’s privacy, dignity and independence was maintained. People were protected from the risk of infection. People’s end of life care wishes was recorded in their care files. Staff were deployed to meet people's needs in a timely manner. People were supported to eat and drink. The provider had not received any complaints since the last inspection. Regular feedback had been sought from people about the service.
Rating:
The last rating of the service was Inadequate (published on 06 October 2022) when we carried out a comprehensive inspection.
At our last inspection we found breaches of the regulations in relation to regulations 9 (person-centred care), 10 (dignity and respect), 12 (safe care and treatment), 13 (safeguarding service users from abuse and improper treatment), 14 (Nutrition), 16 (receiving and acting on complaints), 17 (good governance), 18 (staffing) and 19 (recruitment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We had told the provider what action they needed to take to ensure the safety of people who used the service. At this inspection we found that the provider had made some improvement but remained in breach of regulations.
Why we inspected:
This inspection was carried out to follow up on action we told the provider to take at the last inspection. At this inspection we found that the provider had made some improvement but still remained in breach of regulations 9 (person-centred care), 12 (safe care and treatment), 13 (safeguarding service users from abuse and improper treatment), 18 (staffing) and 19 (recruitment) and 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We identified breaches in relation to lack of risks assessments, risk management plans, detailed care plans, medicines management, safeguarding, staffing, recruitment practice. There were no robust systems in place to assess and monitor the quality of the service provided. There was a lack of effective oversight and leadership of the service.
Enforcement:
This service has been in Special Measures since August 2022. During this inspection the provider demonstrated that improvements had been made. The service is no longer rated as inadequate overall; therefore, this service is no longer in Special Measures.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Brisen Company Limited on our website at www.cqc.org.uk.
Follow up We will meet with the provide to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.