Bracken House

Systems used to complete documentation did not always enable the provider to record people's information in the way they needed to. For example, where the provider had discussed the use of bed sensors with people and had assessed their capacity, this had not been documented.

Quality checks failed to identify where sufficient action had not been taken to address environmental risks in the home. For example, where there was a delay by the building provider in replacing 3 soiled bedroom carpets, the provider failed to arrange for a broken carpet cleaner to be fixed which may have helped to reduce the risk of spread of infection.

Systems in place failed to identify where the provider had not taken sufficient action to ensure visitors to the home were not at risk when using the lift when the light had broken. For example, there was no signage up to make them aware that emergency lighting only was in use.

Quality checks in place did not identify when clinical monitoring checks were not required. For example, staff were required to input records related to bowel monitoring when people did not have any needs or risks related to continence.

People and relatives told us the management team could be more visible in the home.