Coopers Croft

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. This is the first assessment for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safeguarding people from abuse.

This service scored 59 (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 did not consistently promote a proactive and transparent safety culture. Opportunities to learn from incidents and embed best practices were sometimes missed, particularly where potential abuse had not been effectively risk assessed. While systems such as incident and accident logs were in place to support service improvement, their use was not always effective. We found some people’s risks associated with falls had not been assessed effectively. Assistive technology had been put in place in people’s bedrooms to mitigate the risk of falls, however action to reduce the risk of falling when people were in the communal areas had not been put in place. Following the inspection the registered manager took action to mitigate the risk in the communal areas and demonstrated a willingness to learn and responded positively to feedback.

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.A member of the management team assessed people’s needs prior to them being admitted to the service. This enabled them to identify the care and support needs people would require and make sure the necessary arrangements were in place to facilitate a smooth transition.During the assessment, information was obtained from people, and others involved in their care, about people’s individual needs and risks. This information was used to develop individualised care and risk management plans to ensure people received safe and appropriate care and support from the moment they moved into the care home.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately. Prior to the inspection, concerns were raised with us regarding the management of suspected abuse incidents. Although the provider was asked to investigate and respond within a set timeframe, this did not happen, and the registered manager remained unaware of the allegations over 2 weeks later. This failure to act left people at risk, as safeguarding procedures were not reviewed or improved. During the inspection, it was confirmed that safeguarding incidents had not always been managed safely, one incident was not reported to the safeguarding authority, and others were handled inadequately, resulting in a repeat occurrence.

At the time of the inspection, the only member of staff able to raise safeguarding incidents was the registered manager. This meant that when they were not at the service, any potential incidents of abuse may not get reported or acted upon quickly. Following the inspection the registered manager told us that they had begun to train other members of staff to be able raise a safeguarding referral as and when they were required.

For people whose freedom was restricted, the appropriate legal authorisations were sought when needed.

The provider worked with people and their relatives to identify and manage risks during their initial assessment; however, when new risks emerged following accidents or incidents, mitigation actions were not consistently implemented. Care plans and risk assessments did not always contain sufficient detail to ensure safety, particularly in relation to falls and potential abuse. While some documentation offered clear guidance for staff, others had gaps and lacked information to mitigate the risk of further incidents or accidents. This put people at risk of unsafe care.

The provider detected and controlled potential risks in the care environment. They ensured the environment was safe and well maintained. However, a recent event had meant a fire door had been locked with a key. The registered manager had ordered a part for the fire door and was waiting for it to be fitted. The fire risk assessment had not been updated to reflect this locked door and may have slowed down the evacuation process in the event of an emergency.

The upper floor had been designated for people living with dementia. We observed 1 person wandering around looking for their bedroom. There was no signage to support people to orientate themselves around the home. Following the inspection the registered manager told us that the work needed on the fire door had now been completed and they were looking at dementia friendly signage for the upper floor.

The provider ensured that care was delivered by qualified, skilled, and experienced staff who received appropriate support, supervision, and development. Safe recruitment procedures were in place, ensuring staff had the correct requirements to care for people living in the home. New staff received an induction and there was an ongoing programme of regular training for all staff.One person told us, “I’m safe because there is always someone around. I’m not sure there are enough staff on an evening but during the day there is always enough staff.” Another person told us, “When I press the buzzer they answer it quickly.” Another person told us, “I know the staff are checked out. Staff understand the needs of the residents, and they are well trained.”Staff worked well together to meet people’s needs and deliver safe care.

A staffing dependency tool was in place to help determine appropriate staffing levels based on individual people’s needs. However, some staff reported occasions where they felt short-staffed. One staff member told us, “I don’t think there are enough staff to meet people's needs we need an increase of 1 staff on each floor. This has been communicated with the registered manager. When staff are sick or holiday, we are down that staff member.” Another staff member told us, “The morale here is mainly okay but staff are fed up of being short staffed, it’s hard.” This suggested that the staff dependency tool may not have always reflected the day-to-day demands of the service.

The registered manager told us they overstaffed the home on a daily basis so if a member of staff had holiday or sickness they did not always have to fill that position. However, staff feedback did not reflect that this was working. On the day of the inspection, we did not see that people had to wait for their care needs to be met.

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. The home was clean, well-maintained, and demonstrated effective infection prevention and control practices. One person told us, “I’m enjoying it here, it’s so clean everywhere I look. My room is lovely.”Communal areas, bedrooms, and bathrooms were visibly clean and free from unpleasant odours. Staff followed appropriate hygiene protocols, including regular handwashing and the use of personal protective equipment (PPE) where required. Waste was disposed of safely, and infection control audits were carried out to ensure standards were consistently met. These measures helped create a safe and hygienic environment for people living in the home.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.People consistently reported receiving their prescribed medicines at appropriate times. One individual stated, "I get my medicines when I need them, and I can get pain relief when I ask for it." Another commented, "I do take tablets. It’s part of my night time routine. They stop my pain in the night. I get them every night."

Protocols were in place for 'PRN' (as required) medicines, such as pain relief. These protocols guided staff in identifying when a person might need medication, particularly when the individual was unable to communicate their needs directly.

Staff were appropriately trained to administer medicines, and daily spot checks on stock levels were conducted. When errors occurred, the provider took prompt action to minimise the risk of reoccurrence. This included offering additional support to staff and implementing further safeguards when necessary.Random checks of individuals' medicines confirmed that the quantities matched the records on the Medicine Administration Records (MAR), indicating accurate documentation and administration.Medicines were stored securely, with regular monitoring of room and fridge temperatures to ensure safe and compliant storage conditions.