Brackenlea Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe.

The service was in breach of legal regulations both in relation to safe care and treatment and premises and equipment.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Relatives told us they felt able to raise any concerns they had and said they were updated if their loved one experienced any incidents. A relative said, “We have constant phone calls, keeping us updated.”

The provider had processes to ensure staff understood what to report and how. The registered manager and the deputy manager then reviewed any incidents to identify if any changes were required for the person’s safety, or if their care plan needed to be updated. They also checked to see if there were any trends in the types of incidents people experienced or contributory factors which required action, such as people’s medications requiring review. Health care professionals told us staff informed them of incidents, such as falls and ensured any actions necessary were taken.

Staff said any learning from incidents was then discussed with them at the staff shift handover, to reduce the risk of repetition. Following a recent safety incident, all staff had undertaken face-to-face refresher training in moving and handling, to update their skills and knowledge.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff told us they received information about new people, their care needs and any associated risks with their care, prior to their admission to the home. This ensured staff were provided with relevant information about people, to inform the delivery of their care.

We saw people once admitted had emergency admission packs in the event they needed to be admitted to hospital; these included any essential information about the person and their care. Staff said they were then updated about any changes to the person’s care before they returned home from hospital. This ensured they had up to date information post discharge about the person’s care needs and any risks to them.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People’s relatives said their loved ones were safe in the care of staff and that when any safeguarding issues had occurred, the registered manager had taken the correct actions and been open and transparent. We observed people were well treated by staff and well cared for.

Staff had undertaken safeguarding adults and children’s training and understood their role and responsibilities in relation to safeguarding. Staff had access to relevant guidance about safeguarding. The registered manager audited staff’s understanding of safeguarding as well as seeking the views of people and relatives. Staff were heard to inform the registered manager when they noted a bruise on a person, so they could take any actions required.

Staff had received training on the Deprivation of Liberty Safeguards (DoLS) and the registered manager had assured themselves of staff’s understanding through an audit of their knowledge. A person’s relative told us, “[Person] had to have a capacity test for DoLS.” “[Member of staff] phoned me up and told me all about it. She explained everything to me.” DoLS were only used when it was in the person’s best interests and relevant people were consulted about what was in the person’s best interests.

The provider did not always ensure all potential risks to people’s care were understood and managed.

We saw during the first site visit; a person used an air mattress in addition to staff regularly re-positioning them, to mitigate the risk of them developing pressure ulcers. However, there was no guidance on their care plan regarding the correct setting of the mattress for their weight. Staff told us they checked the air mattress daily to ensure it was working properly but did not record their checks. There was a lack of guidance for staff regards the correct setting and a lack of records to show when checks had been completed, this risked either the person’s air mattress being set incorrectly for their weight, or staff not being able to demonstrate when it was last checked. We brought this to the registered manager’s attention who took action to address this.

Staff told us they supported people who had diabetes with their blood sugar monitoring. However, their diabetes care plans lacked details of what their ‘normal‘ blood sugar range was, to inform staff when to seek medical help, as required by the provider’s diabetes policy. We spoke with the registered manager, and this information was then added to their care plans.

The registered manager and staff told us they had completed training on the International Dysphagia Diet Standardisation Initiative (IDDSI), which is a standardised framework to describe texture modified foods and drinks for people who have identified risks with swallowing. However, staff had only completed nutrition training which did not encompass IDDSI training. Several people cared for required a modified diet and although we did not find evidence they had been given unsuitable foods, staff had not completed this training. The registered manager has since told us they plan for staff to complete this training imminently.

However, staff assessed a range of potential risks to people and understood how to manage them. People’s relatives said they felt the risks to people in relation to falling were well managed. A person fell on the day of the first site visit and we saw staff responded promptly and ensured the person was not injured before safely transferring them from the floor. People had access to any equipment they required to mitigate the risks of them falling.

The provider did not always control identified risks within the care environment.

The provider could not demonstrate the identified risks in relation to water safety had been managed. They had not ensured the numerous recommendations from the home’s legionella risk assessment completed in July 2024 had been actioned within the recommended timeframes. Legionella can cause a serious type of pneumonia called legionnaires' disease.The provider still had minimal measures in place to ensure the safe management of hot and cold water, there was a lack of water quality testing and there was not a member of staff trained in legionella, to understand the risks and the full range of checks required. The lack of water safety processes had put people at increased risk of harm from legionella. The provider was able to demonstrate after the site visits that they had taken action during September 2025 and arranged for the required actions to be completed by the end of October 2025. They also arranged for a member of staff to complete legionella training after our site visits.

We also found the thermostatic monitoring valves (TMV’s) had not been serviced annually to ensure they were working correctly. Thermostatic monitoring valves control the temperature of water leaving hot water taps to ensure people are not scalded. The registered manager ensured this was done when we brought it to their attention. A required six-monthly safety check on moving and handling equipment had also been missed. We saw evidence this was completed after our site visits.

We saw during the first site visit, staff had not secured a door where cleaning materials were stored, which risked people accessing them. We spoke with the registered manager who ensured this was locked by our second site visit, but then we found the maintenance cupboard unlocked, which contained a range of manual and electric tools. Although the maintenance person then returned and locked it, leaving it unattended risked people gaining access. We also saw the lid to the sharps box in the medicine room was open during the first site visit, which risked staff being exposed to hazardous items. We saw during both site visit days buckets and mops drying in the garden which did not reflect infection control guidance and they were a trip hazard. The registered manager addressed this when we brought it to their attention.

We saw required safety checks had been completed in relation to electrical, fire and gas safety. Staff completed monthly checks on bed rails where used. Audits were in place to ensure motion sensors where they were used to alert staff people were moving, were working.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager used a tool to calculate and review people’s staffing needs. We saw there were enough staff in each area of the home to keep people safe and to attend to their needs. People and relatives fedback that there were enough staff. Their feedback included, “There always seems to be plenty of staff around” and “I just ring and someone comes straightaway.”

The provider had robust and safe recruitment practices which ensured staff were recruited safely. Once recruited staff received an induction to their role, training and supervisions. The last residents and relatives survey showed people and relatives felt staff were competent in their work. Staff were then encouraged to undertake further professional qualifications in social care.

The provider did not have robust processes in place to control the risk of infections spreading.

There had been an outbreak of Covid-19 within the home from 26 September 2025 and by the 01 October 2025, 5 people had contracted Covid-19. Staff told us there had been a previous Covid- 19 outbreak 2 months ago, when 13 people were infected. People had been exposed to the risks associated with Covid-19 twice recently. There was a lack of any information at the home’s entrance to inform visitors of the outbreak and potential risks before they entered, information was only displayed after we raised this.

We were told during the first site visit the 4 people with Covid-19 were self-isolating. However, we saw 3 people had their doors open, so other people could have entered and been exposed to Covid-19. Staff had not placed clinical waste bins outside their bedrooms, to ensure staff could immediately dispose of contaminated personal protective equipment (PPE) safely. We raised these issues with the registered manager who took action. Staff incorrectly removed 1 person from self-isolation in between our site visits, which risked them spreading Covid-19. The registered manager was not aware and did not know until they were informed by staff the following morning, we saw they then took the required action.

A person with Covid-19 shared a toilet with other people. Staff had not implemented measures to either alert them the person was using the bathroom, or to ensure it was cleaned afterwards. Once we brought this to the registered managers attention, they implemented measures to alert staff the person was in the bathroom. However, we saw staff still forgot to follow guidance and clean the bathroom. There was a risk of Covid-19 being spread.

We saw during the first site visit; a staff member did not directly remove their personal protective equipment (PPE) when they left the room of a person with Covid-19 and another staff member washed their hands in the outer kitchen area having just left the room of a person with Covid-19. We also saw on a number of occasions staff were not wearing their face masks correctly. Staff’s actions risked spreading Covid-19. We brought these issues to the registered manager’s attention, who started to implement the required changes for people’s safety.

The home was visibly clean, and we saw housekeeping staff cleaning the environment. There were plenty of hand sanitiser dispensers. People’s contaminated laundry was managed safely. Staff told us they had completed infection control training, which records confirmed.

The provider did not always make sure all aspects of medicines management were safe.

People’s medicines were not always administered safely. We saw during the first site visit; a tablet was left on a person’s plate in the lounge. Staff had not witnessed the person swallow their medication, as required by the provider’s medicines policy. This person had not received their medication and there was a risk another person could have picked it up. During the second site visit, we saw a member of staff who was administering medication, stop and answer a phone they were carrying, they then left the room to deal with the call. The staff member risked making a medicines error as they were distracted during the medicines round.

We saw whilst all medicines were stored in the locked medicines room. Some medicines were stored within an unlocked cupboard in the medicines room. The provider’s policy required medicines not stored in the medicines trolley, should be locked in cupboards in the medicines room, to ensure their security. We brought this to the registered manager’s attention who told us it would be addressed.

Staff recorded the medicines fridge temperature each morning. It is best practice to record the minimum, maximum and current temperatures to enable staff to identify if the fridge temperature has gone above or below the recommended range within the past 24 hours. However, staff were not recording the fridge temperature range, therefore there was a risk the temperature could have gone either too high or too low.

We saw the instructions for the administration of some people’s medicines lacked sufficient information to enable staff to understand when they should be administered. We saw the instructions for people prescribed Levothyroxine which is used to treat hypothyroidism said to take it in the morning and staff told us it was administered after breakfast. However, it is recommended this medication is taken before breakfast to ensure its effectiveness.

Staff told us people did not have body maps in place, as per the provider’s medicines policy to guide staff about where to apply their topical creams. We spoke to the registered manager who arranged for these to be put in place.

However, staff administering medicines had completed relevant training and had their competency assessed. Staff ensured people’s medicine administration records were complete. Staff had clear guidance about when to administer medicines people took ‘as required.’ Processes were in place to ensure any medicine errors were documented, reported, investigated and any required action taken.