Coppelia House

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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 69 (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.

At a provider level, discussions showed there was a commitment to learn and address areas requiring staff or system improvement. There was investment in new electronic systems to improve the monitoring of standards. This included quality assurance systems and new staff appointments to check standards. Responses to complaints were centrally monitored to ensure lessons were learnt and they were responded to in line with the home’s specific policy. Where there had been incidents, we saw action had been taken to reduce on-going risk and to learn lessons from events.

Staff confirmed they had access to training. There was an internal central training team which provided a broad range of training topics for staff, including around Equality, Diversity and Inclusion, and Workplace Wellbeing. Some were mandatory and others were supplementary. The induction covered key areas of training such as moving and handling, safeguarding, fire training, food hygiene and dementia awareness. Some were face to face and others online.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. However, improvement was needed for the oversight of risk management.

Assessments detailed risks to people’s health and what action should be taken to reduce the risk of harm. For example, the type of equipment they needed to reduce the risk of pressure damage. However, the provider’s internal quality assurance systems identified the registered manager’s oversight of risks, such as completing monthly analysis for falls patterns and themes, required improvement. The registered manager received additional support with oversight and a deadline to make improvements.

Daily handover meetings meant changes and concerns could be shared and acted upon. Staff said the electronic care planning system could be used to flag areas of increased health risks for individuals. The provider’s quality assurance system had identified these were not consistently being set up to assist care staff to monitor people’s well-being. Additional training was offered to address this issue.

There were systems to ensure people were receiving the care they needed. For example, the electronic system alerted staff when a care task had not been completed. We spot checked the electronic system and saw people had been supported with identified care tasks, with the home screen showing when care tasks had been completed.

Staff told us if they noticed a person’s physical or mental health had deteriorated, they would inform senior staff and document any changes. They recognised this as their responsibility to highlight concerns and to continue to observe the person. Senior staff said they would contact external agencies, such as community nurses or GPs for advice, and we saw how they discussed what steps needed to be taken in the meantime.

The registered manager explained the assessment process before someone moved to the home. This included meeting with the individual, their family and contacting relevant health and social care professionals, which showed good practice.

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.

There were procedures for staff to follow if they had any concerns about abuse. Staff responses showed they understood their safeguarding responsibilities and told us they had received appropriate training. The registered manager understood their safeguarding role; they showed us an example where they had made an appropriate safeguarding referral. This demonstrated they also understood the importance of working closely with commissioners, the local authority and relevant health and social care professionals.

People had the option of keeping money in an individual account to pay for expenses such as hairdressing. Money was stored securely, and records were kept and regularly audited. We were assured bank cards were not part of this arrangement. Following the inspection, auditing procedures had been improved by sharing this role between several staff members for added protection.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People spoke positively about how they were supported and showed appreciation around the quality and choice of food. Some people found it more difficult to accept support and we saw staff did not rush them, went at the person’s pace and explained why they were offering help. This was noticeable at mealtimes. A relative said, “My conversations with staff have shown they have a very good understanding of Mum and know her well.” Staff observed people at mealtimes but also gave them space to eat their meals as they chose to. Only intervening when they saw people were struggling and becoming frustrated.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff presence in the communal areas helped support people if they became distressed or required support to reassure them. Staff chatted with people and their conversations showed they knew individuals well. They knew when to intervene or distract people if they became anxious.

We saw people had access to call bells to ring staff when they were in their room. Where people struggled to use a call bell, alarmed mats were in place to alert staff when they needed support.

There were regular maintenance checks to ensure equipment, for example wheelchairs, and safety measures, such as window restrictors were fit for purpose and kept people safe. A fire risk assessment had recently been completed, and the service was waiting for the paperwork, but we were told there were no concerns.

The provider did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, staff worked together well to provide safe care that met people’s individual needs.

Staff did not receive regular formal supervisions, where career progression, training and feedback could be shared. This led to some staff feeling unsupported. The registered manager said they would provide feedback to staff if they saw staff practice showed areas for development, which they identified as supervision.

Some new staff provided positive feedback about the support they had received during their induction and from the staff group.

Several people and their relatives said they wished there were less staff changes. Despite this, people’s feedback on the skills and attitude of staff was positive. They told us staff were ‘very good’ and ‘caring.’ Staff showed good and safe practice when they assisted people to move using appropriate equipment.

There was a mixed response from staff about staffing levels and how staff were deployed around the home. Some felt they had less time on some shifts to spend with people on their preferred routine and instead had to work more quickly. They recognised this was not always appropriate for the needs of people living with a dementia.

Agency staff provided additional support when recruitment was underway or if staff were off sick. The registered manager said where possible they requested agency staff who had previously worked at the service and monitored their performance to ensure they were suited to the people living at the home. The provider assured us there was an active recruitment programme underway.

Recruitment was managed centrally with the registered manager’s input. There were key documents to help ensure new staff were suitable to be working in a care home. We saw some reference information was followed up, to clarify previous employers’ feedback, but not consistently.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were positive about the cleanliness of their room and communal areas. A visitor said their relative’s “room is lovely, clean and tidy and very spacious.”

The home was clean and free from unpleasant odours. Infection control equipment, such as gloves and aprons, were readily available, which staff wore appropriately. Staff told us good infection control practice was an integral part of their role. For example, one said, “Infection control measures are taken seriously, and staff are regularly reminded of protocols to maintain a safe and hygienic environment.”

There were systems to audit infection control and prevention (IPC). The laundry which had been refurbished was clean, tidy and well-organised with processes to manage dirty and clean laundry to avoid cross infection. The provider’s internal quality assurance identified the registered manager’s oversight of infection control required improvement. There was an action plan to address this issue.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and as prescribed. For example, a person told us staff monitored their pain well and their medicines were administered on time. We also saw how staff discretely gave medicine to people during a lunch time meal, which maintained their privacy.

Staff ensured medicines and treatments were managed and stored safely. Staff had received relevant training, and their competency was checked to ensure they managed and administered medicines safely. However, staff administering medicines said they were often interrupted, which potentially could result in mistakes.

There were systems to ensure regular internal and external audits with checks undertaken to ensure medicines were safely administered and stored. The provider’s internal quality assurance in June 2025 identified areas for improvement. The provider’s quality assurance process identified areas for improvement in medicines. A new staff member was recruited during the inspection process and their specialisms included medicines. Part of their role was to review how medicines were being administered and managed.