CQC report explained · a residential care home
What the CQC found at Bracken Tor House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risk assessments, staffing, medicines and emergency plans were generally managed safely, although changes were needed in the laundry room to reduce infection risks.
- Effective?
- Requires improvement
- People were supported with food, health care, training and independence. However, restrictions on leaving the home were not initially supported by the required capacity assessments and legal safeguards.
- Caring?
- Good
- People were treated with dignity, kindness and respect. Staff knew people well and involved them in care decisions and everyday choices.
- Responsive?
- Good
- Care plans reflected people's individual needs, preferences and risks. People chose their activities and staff used suitable communication methods where people had limited verbal skills.
- Well-led?
- Good
- The home had an experienced manager, a person-centred culture and systems for checking quality. Feedback from people, relatives and staff was used to make improvements.
What inspectors found, May 2019
Rated Good overall; inspectors found kind, personalised care, but Effective Requires Improvement because legal safeguards and laundry arrangements were not always right.
This was an unannounced, planned comprehensive inspection on 21 March 2019. One inspector visited, spoke with four people, a relative, the manager and three staff, and reviewed care, medicine, staff and quality records.
The home was rated Good overall. Safe, Caring, Responsive and Well-led were also rated Good. Inspectors found people were treated with kindness, supported to make choices, and encouraged to be independent and involved in their community.
Effective was rated Requires Improvement. Some restrictions on people leaving the home had not initially been supported by the required capacity assessments or legal applications. The laundry room also needed changes to reduce the risk of infection spreading.
After the inspection, the manager provided evidence that capacity assessments had been completed and that a legal application had been made for one person. The manager also gave details of planned changes to the laundry room. The previous overall rating was Good, published on 13 October 2016.
Kind and respectful care
Inspectors saw a relaxed and happy atmosphere. Staff had strong relationships with people and supported them with dignity and affection.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Choice and independence
People were encouraged to make decisions, take part in daily tasks and choose activities in the home and community.
“People were encouraged to live as independently as possible.” from the report
Personalised support
Care plans described people's individual needs, risks, preferences and communication methods. People were involved in developing and reviewing their plans.
“People's care plans described personalised care and support which reflected the risks, needs and preferences of people.” from the report
Safe medicines and staffing
Staff were safely recruited and trained. Medicines were stored, given and recorded safely, with regular checks.
“Medicines were managed safely. Medicines storage systems were organised and people were receiving their medicines when they should.” from the report
Legal safeguards for restrictions
needs fixingPeople could not leave the home without staff support, but the required capacity assessments and legal applications had not been completed at the time of the visit. The manager later provided evidence of action, including an application for one person.
“However, people were not free to leave Bracken Tor without staff support because of the risk this would pose to their safety.” from the report
Laundry room infection risk
needs fixingThe laundry room had no nearby hand-washing facilities and did not separate clean and dirty washing. Cleaning equipment was also kept there, so changes were needed to reduce cross-contamination risks.
“The laundry room was very small and did not have hand washing facilities within it or close by.” from the report
- 01Have all restrictions on people leaving the home now been supported by capacity assessments and the correct legal safeguards?
- 02What changes were made to the laundry room, and how are you checking that clean and dirty washing remain separate?
- 03How do you review whether each person can safely manage their own medicines?
- 04How are people and their relatives involved in reviewing care plans and decisions about risks?
- 05How do you use feedback from people and relatives to make improvements?
This was a planned comprehensive inspection of the care home and all five CQC questions; the Reach Out personal care service was not inspected. This explanation was written from the published report of 3 May 2019 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, October 2016
Rated Good; inspectors found kind, person-centred care, with minor issues about complaint information and on-call arrangements.
This was an unannounced inspection on 21 September 2016. The inspector spoke with people living at the home, a person using the agency, family representatives, staff, the registered manager and a health care professional. Care plans, medicine records, recruitment records, meeting notes and audits were also checked.
The home and agency were rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found staff knew people well, treated them with kindness and supported their health, choices, independence and activities.
There were a few small issues. Reach Out staff did not have the details of the on-call person readily available. The complaints procedure was not in a format some people were likely to be able to use. The report says there had been no formal complaints.
Person-centred support
Staff knew people well and planned care around their individual needs, choices and preferences.
“People using Bracken Tor and Reach Out received a person centred service from staff who knew them well.” from the report
Kind and respectful staff
People's privacy, dignity and choices were respected. Staff built strong relationships with the people they supported.
“Care workers spoke about people in a respectful manner, in a compassionate and caring way answering questions in a way which put the person using the service as the priority.” from the report
Good management and monitoring
The service had a settled manager, supportive staff teamwork and systems for checking care quality and safety.
“There were effective arrangements in place to listen to people's views and monitor the standard of service provided.” from the report
On-call details
minorStaff working through Reach Out could not see who was on call at any particular time. They had to ring the home to find out.
“However, staff working for Reach Out did not have the details of who was on call at any one time, which meant they had to ring Bracken Tor to find out, which they said was frustrating.” from the report
Complaints information
needs fixingThe complaints procedure was displayed, but its format meant some people were unlikely to be able to use it. The manager said a pictorial version was planned.
“A complaints procedure was displayed in Bracken Tor but people were unlikely to be able to use it because of the format in which it was displayed.” from the report
- 01Has the service made the on-call contact details readily available to Reach Out staff?
- 02Is the complaints procedure now available in a pictorial or otherwise accessible format?
- 03What is the current position on the DoLS applications mentioned in the report?
- 04How are people's meal preferences recorded and checked in practice?
- 05How does the service check that care plans and medicine records remain accurate and up to date?
This was an unannounced inspection covering the overall service and all five CQC questions, including both Bracken Tor and Reach Out. This explanation was written from the published report of 13 October 2016 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 Tor House
2 rated inspections over 3 years: the service has held its Good rating throughout.
- May 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- October 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 24 November 2010.
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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
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