Brackenlea Care Home

On this page

• 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 good. 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 care.

The service was in breach of legal regulations in relation to governance.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider’s statement of purpose set out their aims and objectives for the delivery of people‘s care. The provider had a clear mission statement for the service and values which underpinned the delivery of people’s care. Their values included family, respect, dedication, teamwork and passion. A relative said, “They [staff] care for the whole family.” We observed staff were kind and caring towards people, whom they spoke about positively and warmly.

Leaders whilst compassionate, capable and inclusive needed a greater level of oversight.

We saw the registered manager and deputy manager’s office was located on the top floor of the home. The registered manager told us the office had been re-located up there about a year ago. Although they both come down frequently across the day, for the staff handover, a daily walk around and to complete audits and observations and to respond to people and staff. The managers were not as visible or readily accessible as if they were based on the ground floor with the staff team. There was always a senior carer who led each staff shift whom had had oversight of the care delivered by staff during the shift. They rang the managers if needed or walked upstairs to their office.

The registered manager told us following our findings from the site visits they needed a greater level of oversight of staff’s work and that they planned to base themselves on the ground floor for part of each day. We found shortfalls as described in the report which had not been identified by the managers prior to our inspection. This indicated the managers required some aspects of further skills and knowledge development.

There had also been changes within the organisation, and for example, the provider’s nursing officer who had provided support to the home with areas such as the service contracts had left earlier in the year. Therefore, there was less support available to the registered manager from the head office.

However, the registered manager and the deputy manager who were both very experienced worked closely together. The staff survey showed staff felt the manager was a good role model, whilst the last relatives survey, showed they felt the home was competently managed.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistleblowing policy and there were opportunities for staff to speak out about any issues. Staff could speak directly to the registered manager, or the provider, or they could speak up at staff meetings, at their supervision or through the staff survey. Staff told us, they felt they could speak openly with management about issues. We saw evidence that when any issues were raised, they had been thoroughly investigated, and any required actions had been taken.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had an equality and diversity policy. The registered manager recognised the benefits of a diverse workforce and was committed to providing a working environment that was free from discrimination. We saw there was diversity in the staffing and staff we spoke with felt well supported in their role, which was also the finding of the last staff survey.

The provider did not have good governance. They did not always act on the best information about risk.

The provider had not ensured health and safety findings were acted upon promptly and robustly. The legionella risk assessment completed on 30 July 2024 identified 42 high priority actions which required completion within a month of the report and 11 medium priority actions which required completion within 3 months. Records showed the report was given to the provider on 30 October 2024. However, action was not taken until almost a year later and at the time of CQC’s site visits remedial work had not commenced. People had been placed at risk for almost a year after the legionella report’s findings were known.

The provider had not identified at the time that the required six monthly safety check on moving and handling equipment had been missed. The registered manager told us this was due to a change in contract; however, processes were not in place to identify that the new contract had not been fulfilled and essential safety checks had been missed. The provider had not identified the annual TMV checks had not been completed. People had been placed at risk as essential safety checks had not been completed.

The registered manager and staff completed a range of audits, but they had not identified the issues we found at this inspection as described elsewhere in this report. In relation to the management of infection outbreaks, PPE use, equipment, safe care, medicines or the environment. The provider had not identified that no one was trained in legionella awareness or that staff had not completed IDDSI training. People had therefore been exposed to these risks.

The provider had an annual audit schedule. However, many of the audits completed were based on the Care Quality Commission’s (CQC’s) old inspection framework. The audits had not been updated to reflect CQC's current assessment framework. The registered manager has since the site visits provided evidence that they have obtained current checklists for each of the 5 key questions to enable them to better identify and be able to demonstrate the required evidence is available for each question.

The provider had robust policies. However, staff were not always following them in relation to infection control, PPE use, medication administration and storage or diabetes care planning. This placed people at risk of receiving incorrect or unsafe care.

Staff had made some incorrect entries with regards to the IDDSI level of foods provided to people. Staff had recorded people had been given foods of one IDDSI level, when they had received a different level. Although we were satisfied people had received foods of the correct consistency for their needs. Staff had not always recorded the details of the foods provided accurately and the errors in their recording had not been identified by the audit processes.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff ensured referrals were made to a wide range of external agencies and professionals as required. A health care professional told us staff made appropriate referrals to their service as needed and that staff attended any training they organised. We saw feedback from another professional about how openly staff had worked with them to ensure a person’s safety.

Staff engaged with the community, the vicar visited and there were garden parties and Christmas parties. Staff also took people to the school to listen to the children singing. A person’s relative told us how staff had taken their loved one to the football and stopped in at the pub on the way back, and how they had ‘absolutely loved it.’

The provider did not always focus on continuous learning, innovation and improvement across the organisation. They did not always actively contribute to safe and effective practice.

The quality assurance processes in place were not fully robust and had not consistently identified areas of risk. They had not always identified those aspects of the service which required improvement, nor had they always ensured the required changes identified had happened. As evidenced by the issues we identified at this inspection.

However, both the registered manager and the provider have taken positive action in response to our feedback from the site visits, as detailed within the report. They have been proactive in initiating actions to address the required changes.