Brisen Company Limited

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• 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 inadequate. 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 provider is in breach of legal regulations in relation to fit and proper persons employed and good governance.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us there was a positive culture within the service. Staff were clear about the aims and objectives of the service. They told us they aimed to delivered person centred care with the best outcomes for people, and in their opinion they were delivering this. Staff also told us the provider had made lots of improvements since the last inspection. Comments included, “We are trying to make things better as a team. I think there has been lots of improvement. The service users are a lot happier which shows you things have improved.”

We were not assured leaders had the skills, knowledge, experience and credibility to lead effectively. This service has been rated less than good and had multiple inspections, despite some improvements remains in breach of legal regulations. There have been issues with recruitment at previous inspections and we found further issues at this assessment and the provider was failing to recruit staff safely. Some staff had been recruited without obtaining any references. The provider was also failing to obtain a full employment history as gaps in employment were not always investigated. Employment dates on application forms did not always correspond to the dates given on the reference. This was an ongoing breach of legal regulations. Notwithstanding these ongoing concerns staff gave positive feedback about the leadership and management of the service. They told us the registered manager was responsive, compassionate and listened to concerns raised. The registered manager was also engaging in external networks and undertaking training in order to improve their understanding of their regulatory responsibilities

The service fostered a positive culture where staff felt they could speak up and their voice would be heard. Staff were regularly reminded about whistleblowing and they were encouraged to raise any concerns they had. One member of staff told us, “We discuss this during the meetings. If I had any concerns I would speak to the registered manager. I would also speak to the local authority or CQC if necessary. I don’t have any concerns as the registered manager is very responsive.” The provider also gathered feedback from staff through satisfaction surveys. Feedback was mainly positive; however the results of the feedback had not been analysed to identify areas of potential improvement.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was an equality and diversity policy in place which described general ambitions to ensure all staff would be treated fairly. The provider also offered flexible working to support staff with disabilities and/or caring responsibilities. Staff told us they appreciated this supportive and flexible approach. One member of staff said, “The registered manager has been very supportive and flexible when I needed it.”

At our last inspection, the provider had failed to ensure systems for the governance and management oversight were robust, safe and effective. At this inspection, we found insufficient improvements had been made. There was a system of audits and quality assurance checks but these had not all been effective as they had not identified the issues we found with medicines, care plans, risk assessments and recruitment. Despite some general improvements with staff timekeeping the provider did not have a robust process or auditing ECM data to identify themes and trends.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. There was good evidence of working in partnership with people receiving care, their relatives and other external health and social care professionals. People told us the registered manager communicated with them well and was available if they had any concerns about their care. Comments included, “I can contact the registered manager easily” and “The registered manager is very hands-on. I get check-up calls and she will visit and we will have a long discussion.” People told us they were satisfied with their care and would recommend the agency to others. Comments included, “The staff are very responsive and they take particular care of my [family member] and they do a very good job” and “I would recommend this company. They are reliable and the staff have been lovely and helpful.”

Despite positive comments from people and staff we could not be assured the provider was always focused on continuous learning, innovation and improvement. Despite a range of improvements, insufficient improvements had been made in some key areas which showed improvement plans had not been entirely effective. We raised our concerns with the quality of records in relation to risks, medicines, audits and recruitment and the provider has made some immediate improvements, however further improvements are needed to ensure improvements will be embedded and sustained going forward. The provider has also told us they are now actively recruiting another registered manager to improve the governance and oversight of the service.