CQC report explained · a residential care home
What the CQC found at Bracken House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Good
- People said they felt safe. Staff were trained in safeguarding, risks were recorded, staffing was considered sufficient, and medicines were generally administered safely, although some topical creams did not have use-by dates recorded.
- Effective?
- Requires improvement
- This question was not inspected during this focused inspection.
- Caring?
- Good
- This question was not inspected during this focused inspection.
- Responsive?
- Good
- This question was not inspected during this focused inspection.
- Well-led?
- Requires improvement
- Management systems and audits did not always identify or resolve environmental risks, and some decision-specific mental capacity assessments were not recorded. The provider was no longer in breach of the earlier governance regulation, but further improvement was needed.
What inspectors found, December 2023
Bracken House is rated Requires Improvement; inspectors found people were generally safe, but checks and records did not always identify or address risks.
This was an unannounced focused inspection after concerns about falls, medicines and how the home was managed. Inspectors visited on 17 and 23 October 2023, spoke with people, relatives and staff, and reviewed care, medicines, staff and management records.
The safe rating improved from Requires Improvement to Good. People said they felt safe, staffing was considered sufficient, medicines were generally given safely, and risks such as falls and moving and handling were managed. The home was generally clean, although some carpets were stained and one caused an odour.
The well-led rating remained Requires Improvement. Management had made improvements and was no longer in breach of Regulation 17, but checks had not always identified environmental risks or missing mental capacity records. The overall rating remains Requires Improvement and has been at this level for the last two inspections.
People felt safe
People and relatives said they felt safe. Staff knew how to recognise and report abuse, and risk assessments guided staff in areas such as moving and handling.
“People were supported by competent staff who made them feel safe.” from the report
Safe staffing and recruitment
People and relatives said there were enough staff to meet needs. Staff had checks and references before starting work.
“People were supported by staff who were safely recruited.” from the report
Learning from incidents
The provider analysed accidents and incidents to look for patterns. Changes were made after falls and medicines errors to reduce the chance of problems happening again.
“The provider completed a high level analysis of accidents and incidents that identified patterns and trends.” from the report
Positive interactions
Inspectors saw staff engaging with people in a person-centred way. People and relatives described the home as a positive place to live.
“We observed a positive culture at the home. Staff engaged with people in a person-centred way and people seemed empowered by their interactions with staff.” from the report
Environmental risks were not followed up quickly enough
needs fixingThree bedrooms had stained carpets and one had an odour. The broken carpet cleaner was not repaired until inspectors raised the issue, and there was no sign warning visitors that only emergency lift lighting was working.
“Quality checks failed to identify where sufficient action had not been taken to address environmental risks in the home.” from the report
Some mental capacity decisions were not recorded
needs fixingThe home had discussed bed sensors and assessed capacity, but the decisions were not documented. Management said computer system limitations had contributed and later said this would be addressed.
“where the provider had discussed the use of bed sensors with people and had assessed their capacity, this had not been documented.” from the report
Some medicines records were incomplete
minorSome topical creams did not have use-by dates recorded. The manager said this would be addressed immediately.
“Some topical creams did not always have use by dates recorded on them.” from the report
- 01What has been done to replace the three stained bedroom carpets, including the carpet that caused an odour?
- 02How do you now make sure environmental risks, such as broken equipment or lift lighting, are identified and dealt with promptly?
- 03How are decision-specific mental capacity assessments and best-interest decisions recorded, including decisions about bed sensors?
- 04How do you check that topical creams have use-by dates and that all medicines records remain complete?
- 05What progress has been made since this inspection to move the overall rating above Requires Improvement?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 14 December 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2022
Rated Requires Improvement; inspectors found kind, responsive care, but weaknesses in care records, staff skills, medicines checks and management oversight.
This was an unannounced inspection on 18 October 2022. Inspectors spoke with people, relatives and staff, observed care, and checked care records, medicines records and management information. The inspection was prompted partly by concerns about infection control, food and drink, risk management and building safety.
The home was rated Good for Caring and Responsive. Inspectors found kind staff who respected people's choices and dignity. People had support with meals, health needs, activities, communication, relationships and complaints.
The home was rated Requires Improvement overall, and also Requires Improvement for Safe, Effective and Well-led. Care plans and risk information were sometimes incomplete or conflicting. Medicines stock records were not always accurate, staff needed more dementia and Mental Capacity Act knowledge, and management checks had not found these problems. The provider was told to make improvements.
Kind and respectful staff
Inspectors found that staff took time to know people and supported their choices, dignity and independence.
“People were supported by kind and caring staff who took time to get to know people's needs and preferences.” from the report
Personalised support
Staff understood people's histories, preferences and communication needs, and used this information to involve people in their care.
“People's preferences were understood by staff. People and relatives told us staff ensured their preferences were met.” from the report
Activities and relationships
People were supported to keep in touch with relatives and take part in activities that suited them.
“People and their relatives told us there were lots of opportunities to take part in activities.” from the report
Safe medicine administration
Although stock records were not always accurate, inspectors saw medicines being stored and given safely and as prescribed.
“We observed staff administering people's medicines and this was done in line with current guidance.” from the report
Incomplete risk information
seriousSome risk assessments were out of date, lacked detail or contained conflicting information. This could leave staff without clear instructions.
“Risk assessments and plans to minimise risks were not consistently documented.” from the report
Medicines stock records
seriousMedicine stock counts did not always match the records. Inspectors said this created a risk that someone could run out of their medicine.
“The providers medicines systems were not maintaining accurate stock balances of people's medicines.” from the report
Dementia and capacity skills
needs fixingSome staff did not consistently show they had the skills to support people with dementia or distressed behaviour. Capacity assessments and staff understanding of DoLS also needed improvement.
“Staff did not consistently demonstrate they had the skills to support people with dementia.” from the report
Management checks
seriousThe provider's monitoring systems had not identified or dealt with the gaps in care records, staff skills, capacity assessments and medicines checks.
“The provider had failed to ensure the governance of the home was effective in identifying areas for improvement and taking required actions to keep people safe.” from the report
Environment needs refurbishment
minorThe home needed improvements to decoration, flooring and furniture. Inspectors also recommended considering adaptations for people living with dementia.
“The home required refurbishment. There were areas of decoration which required updating and floor covering which required replacing.” from the report
- 01What has changed in the care planning system so that risk assessments are complete, current and consistent?
- 02How do you now check medicine stock balances, and what happens if the records do not match?
- 03What additional dementia and Mental Capacity Act training have staff completed, and how is their competency checked?
- 04How do you make sure capacity assessments and best-interest decisions are completed when someone may lack capacity?
- 05What refurbishment work has been completed, and what changes are planned to make the environment more suitable for people living with dementia?
This was the first comprehensive inspection since the service was registered in 2020 and covered all five CQC questions, the premises and the care provided. This explanation was written from the published report of 1 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bracken House
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2021
Registered with the Care Quality Commission on 8 July 2021.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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