Copper Beeches

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 newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 66 (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 not always had a proactive culture of safety.

There was a process in place for recording accidents and incidents, and staff acted following these to monitor and manage risks for people. A relative told us about when their loved one had a fall. They said, “[Staff] have had to get an ambulance to come, they are very good at letting me know.”

However, there was not always evidence to demonstrate that management had thoroughly reviewed incidents in a timely manner. For example, although leaders completed a monthly review of incidents and accidents, the data for these events was not always clear or accurate. A falls audit from March 2026 recorded no falls at the service but the service incident log showed there had been falls in March. This meant management did not always have effective oversight of incidents and accidents and there was a missed opportunity for identifying patterns or trends and any wider learning for the service.

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 relative told us, “We came and looked (before our loved one moved in).”

People’s needs were assessed prior to them moving into the service and then were regularly reviewed. A staff member told us, “When admitted we draw up [people’s] care plans. We would look at all elements of risk and complete risk assessments.” Another staff member said, “Any new clients we would read [the care plan] before we start working with them.” Daily ‘flash meetings’ were used to share updates on risks, care needs, medicines, and any changes. This supported staff to provide continuity of care for people.

The service had made referrals to external professionals, such as speech and language therapy and tissue viability services when needed and care plans reflected the professional guidance given to support staff to meet people’s needs.

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 were safeguarded from abuse. Staff had received safeguarding training and demonstrated an understanding of safeguarding. They knew how to report concerns, including escalating concerns to senior staff or external agencies where needed.
There were processes in place for reporting safeguarding concerns to the local authority and a log was kept to enable leaders to keep track of the progress of any safeguarding concerns. Leaders described using root cause analysis for safeguarding concerns and told us they shared lessons through team meetings.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. DoLS applications and authorisations were in place for people around any restrictions within their lives that they did not have capacity to consent to. Systems to review these were also in place. The service had a designated MCA and DoLs champion in place to ensure good practice in this area.

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 and relatives, where appropriate, were involved in managing risks to people’s health and wellbeing. Care plans contained detailed, personalised information about risks in relation to nutrition, mobility, and skin integrity. There was clear guidance in place for staff to follow for monitoring and mitigating risks to people. We observed staff followed the guidance in people’s care plans in practice. For example, where people were at risk of their skin breaking down this was highlighted in their risk assessment and guidance was in their care plan about supporting skin integrity. A staff member told us, “With bed sores we do repositioning. The care plan will show when [people] were last moved, and we do it every four or two hours depending on the person.” People’s repositioning charts typically showed regular re-positioning in line with the individuals care plan.
Staff described working with families and professionals to review risks and make changes. Staff gave an example of adapting moving and handling approaches for a person who they observed became distress during support to mobilise to reduce the person’s concerns.

The provider did not always review and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Although the home was clean and free from odours, there were concerns about the use of space and maintenance of safety checks. Bathrooms were used for storage of mobility equipment and linen trolleys, which posed risks to hygiene and access. Records showed gaps in environmental safety checks, including mattress and bed rail checks.
Some areas of the service required redecoration and were not dementia friendly, the provider had already identified this and was in the process of refurbishing the service at the time of this inspection. Leaders told us they were looking to introduce a ‘dementia lead’ to improve the environment in line with research in this area. A relative said, “The building is much better now, you can see the improvements.”

Other environmental safety checks had been completed as required such as gas safety, legionella testing, and equipment servicing. Care staff told us they helped maintain a safe environment by making sure there were no hazards, removing clutter and following moving and handling guidelines when using equipment to support people to mobilise.

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

The provider had recruited staff safely. They carried out appropriate pre-employment checks such as obtaining staff references and completing Disclosure and Barring Service checks as required.

The provider carried out a dependency assessment to ensure there were sufficient levels of staff to meet people’s needs. There were enough staff deployed to meet people’s needs, and planned staffing levels were observed during the inspection. Staff told us, “There is always a carer there in minutes should a person need support.” Another staff member said, “There is enough, I can tell, we meet all people’s requirements.” A relative said, “I do think there are enough staff, they are very good and this is what they are like, they are not putting it on.”

The provider had recently reduced reliance on agency staff and recruited new nurses, which supported continuity of care for people. Nurses were registered with the Nursing and Midwifery Council. The provider had made checks on their personal identification number, registration status and renewal date. The service provided staff with mandatory training as well as additional training to support their skills. Leaders monitored staff training to ensure it remained up to date or planned for when it was due to expire. Staff reported good teamwork and said support was available when needed although staff had not always received regular supervision. The provider had a plan in place to ensure staff received regular supervision in future.

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.

Dedicated housekeeping staff and an infection prevention and control champion were in place to maintain the service. Staff had received infection prevention and control training and demonstrated awareness of good practice. For example, staff knew cleaning processes, used personal protective equipment (PPE) and maintained hand hygiene to avoid cross-contamination risks.

The service was observed to be clean, with no unpleasant odour. A staff member told us it mattered to them “maintaining the cleanliness in [people’s] rooms. I do a good job keeping their space clean where they cannot do it themselves.” A relative told us, “They are always cleaning I like that."

The provider did not always make sure that medicines and treatments were safe and met people’s needs.

We found incidents where there had been discrepancies in people’s medicines stock in recent months. Action had been taken by nursing staff at the time to ensure people had not come to any harm and there was no evidence of impact to their care, however possible causes of the stock discrepancies were not always investigated. This meant there were missed opportunities to learn lessons and improve medicine practice at the service over time.

Despite this, other areas of medicine management had been well maintained. Medicines were stored safely. Staff had received training to administer medicines and had their competency assessed. The service used an electronic medicine administration system and recorded when people had been administered their medicines. People also received any ‘as required’ (PRN) medicines they might need. For example, PRN medicines to manage constipation risk were given in line with people’s risk assessments and care plans. People’s medicines were reviewed with relevant others and changed when required. For example, where people required their medicines to be administered covertly and in their best interest appropriate decision making processes had been completed and recorded.