Copper Beeches

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.

This is the first assessment for this newly registered service. This key question has been rated 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, person-centred care.

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 and was working to improve the culture within the service, although this was still being embedded. Leaders told us they were still working on the culture at the service with a focus on improving care quality, staff development and moving away from a previously “task orientated and institutional” approach.

There was evidence of positive cultural change, including ‘daily flash’ meetings where staff shared updates, raised issues, and celebrated achievements. These meetings were observed to be inclusive of different departments in the service.

Staff feedback about the culture was mixed. Some staff told us that “everyone gets along well,” while others said there were some staff dynamics across the care team which were ongoing. Leaders were aware of this and were working to improve staff confidence and engagement. Staff dynamics were discussed during staff meetings and respectful, two-way interactions were encouraged.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were visible, approachable and actively involved in the day-to-day running of the service. During the inspection, the manager engaged positively with people and staff, demonstrating compassionate interactions and a good understanding of people’s needs.

Staff described leaders as supportive. A staff member told us, “The managers are good and ask if we need help.”

Clear management structures were in place and there was regular communication between the manager and regional manager. Leaders spoke about reflective practice and developing staff through mentoring, which supported a positive learning environment.

People did not always feel they could speak up and that their voice would be heard.

Some staff told us they felt able to raise concerns and that these would be acted upon. For example, 1 staff member said, “Yes I can very much so” when asked about raising concerns. Whereas another staff member told us they were not always confident their concerns would be heard or acted on effectively by all senior staff. This inconsistency meant the culture of speaking up was not fully embedded, and further work was needed to ensure all staff felt able to raise concerns and confident they would be robustly addressed. Following the inspection, the provider told us they had carried out a staff survey which demonstrated most respondents felt positively about management and identified areas for further improvement. An action plan with clear timescales was developed to address the feedback received. This demonstrated the provider was taking action to strengthen staff confidence in speaking up and raising concerns.

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 promoted equality, diversity and inclusion within the workforce. Staff received equality training and most told us they felt treated fairly and respected. Leaders demonstrated awareness of staff wellbeing and supported flexible working arrangements where required, such as adjusting shifts to meet staff’s personal needs.

The provider did not always have good governance processes in place. They did not always act on the best information about risk, performance and outcomes.

The provider did not always have effective systems to ensure robust governance and oversight. While there were systems in place, including oversight from senior leaders, audits and meetings; these were not consistently effective in identifying and addressing issues.

For example, there were multiple systems and processes for recording accidents and incidents. The provider could not provide a clear and accurate report for us during the inspection for the number of accidents and incidents that had taken place in relation to falls and medicine errors. This meant the provider did not have clear oversight in these areas.

Audits we reviewed identified some areas where the service was not fully compliant. The audits had a prompt to complete an action plan to make improvements however, we found that this was not always completed. Although we saw evidence that some areas that were not previously fully compliant were address by the next audit, there were some other areas where there was no evidence of robust action being taken to prevent the same issues from re-occurring. For example, monthly medicine stock checks found issues with discrepancies or too much and too little stock for some medicines for some people.

Individual review of incidents showed appropriate action taken to manage and mitigate risk for people for in those instances however there was not always evidence that wider patterns, trends or lessons learnt had been identified by management. This meant the service could not effectively learn and improve. In addition, the health and safety audit for the last 2 audits had highlighted the manager had not reviewed incidents and accidents within 72 hours. This demonstrates robust action was not taken to ensure this process would be consistently met in future.

Leaders told us they were aware of some areas for improvement in their existing governance process and planned to change the systems in the future.

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.

The provider worked in partnership with other organisations to support people’s care. Staff described positive relationships with external professionals. A health and social care professional was positive about their experience of partnership working with the service. They told us, “I find the staff friendly and have an attitude to help me. I have also seen that they make time to communicate with people’s family.”

The service supported people to maintain relationships, and visitors were welcomed. Feedback showed people visited their loved ones throughout the day and at any time when they became unwell.

The provider had made some improvements to the service with some still in progress and some had not yet taken place. This meant there were some areas where they were not able to demonstrate a consistent approach to learning and improvement.

Although audits were robust in identifying areas of practice which required improvement, these had not always led to actions being taken as outlined under the governance, management and sustainability quality statement. Patterns and themes around accidents and incidents had not been robustly reviewed to support future learning and reduction in similar occurrences. Leaders told us they had identified a need to make changes to their auditing system to address this and planned to do this in the future. We will check this at our next inspection.

Some systems and processes for gathering formal feedback were still being developed such as surveys, monitoring of visitor feedback and staff supervision. This limited opportunities for structured learning from stakeholders.

Overall, further work was needed to ensure learning was consistently captured, shared and embedded to improve outcomes.