Coppice 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 changed to 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 people’s safe care and treatment.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service did not always have a proactive and positive culture of safety. Risks to people were not always used to learn and improve. For example, incidents within the home were not always recorded. Therefore, the service could not effectively monitor for themes and trends.

The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

The service worked with healthcare providers to manage and monitor people safely. However, this input from healthcare providers did not always transfer to people’s care. For example, where the service had sought the support of healthcare professionals in a person’s care, advice and guidance from the professional was not always transferred to care records about the person.

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.

The provider had a training programme in place for staff to support people safely who became distressed. These interventions at times may involve the use of some form of physical restraint. Where this was being used in line with the provider policy, these incidents were not recorded appropriately, escalated to the manager, reviewed accordingly and staff given the opportunity to de brief. In one case it was not clear why a particular form of restraint had been used.

The service notified CQC of safeguarding concerns and informed the local authority in most cases.

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. We found that the service was making the appropriate DoLS referrals. Not everyone who required a DoLS had been assessed by the supervisory body at the time of our assessment..

The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments relating to the health, safety and welfare of people using the service were not always completed. This meant plans were not always in place to support people to manage risks.For example, people who were at specific risk of constipation did not have the appropriate care plans and risk assessments in place to give appropriate guidance to staff and help people to stay safe. People at the service could not consent to their care. This meant people at the service relied on staff to make judgements about their care to help them stay safe. Risks to people were not clearly understood by the management team. These risks were not identified in people’s care plans. We found 4 people’s care plans who used laxatives to support with constipation did not have the necessary assessments in place to help staff understand people’s needs, what the risk was and when and how to support people safely. Staff were not accurately recording people’s bowel habits and using prescribed interventions as directed by the GP. Records we viewed showed people were not opening their bowels for a number of days with no escalation in place by the service. This put people at increased risk of harm, this was further compounded by people not being able to tell staff if they were in discomfort. There was no information in care plans about what signs staff should look for if a person may be experiencing constipation.

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

During the assessment we identified hazards including half empty bottles of cleaning chemicals and an open gate to the in the outside area which could pose a significant harm to people. Internally we found a person’s room had broken furniture in it, which had previously been removed by the manager because it was broken. This furniture had been put back into the person’s room by staff. We addressed our concerns with the manager and provider. Action was taken immediately to address the environmental concerns.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs. The provider did not always ensure staff received sufficient training for their roles. For example, where people had specialist needs, such as, a learning disability or higher risks due to the service user group, staff had not received training to support these people safely. Staff had not received part 2 of the required learning disability training, some staff were out of date with communication training, person centred care and positive behaviour support training. Staff had not received specific training around constipation in people with a learning disability and autistic people.

This placed people at increased risk of harm. However, the provider did ensure staff received regular supervision and appraisals.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service did not always have an effective system in place for storing cleaning chemicals safely. We found not all staff understood how to keep cleaning products safe from people who would be at risk of harm. People’s laundry was not being separated effectively increasing the risk of cross contamination. The washing machine was broken on arrival with washing being transferred between services. There did not appear to be an effective infection control protocol in place for this. The washing machine was fixed during the assessment..

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

The service did not have safe systems to monitor, review and manage people’s medicines safely. People were at serious risk of harm due to the lack of accurate risk assessments and protocols in place to support people and staff. The management team and staff did not understand the level of risk of harm to the people they were supporting with certain health conditions.

A review of medicines administration records (MAR) charts showed people received their regular medicines as prescribed. However, medicines prescribed with variable doses or on an ‘as required’ (PRN) basis were not always administered in line with prescribing instructions or in response to people’s needs. Some people were prescribed PRN laxatives to manage constipation. Although PRN protocols and care plans were in place, these did not always contain person-centred information, such as the individual’s normal bowel pattern. This meant staff did not have clear guidance to recognise when a person was becoming constipated or required PRN medicines.

Staff were not following prescribed medicine guidance by the GP. This put people at significant risk of harm. People were unable to tell staff if they were in pain or discomfort, increasing the risk of harm for people.

One person had gone 12 days without a bowel motion. Despite this, there was no evidence concerns were escalated to the management team or the GP as outlined in protocols. Prescribed laxatives were not administered or adjusted in line with prescribed dosage instructions, care plans or protocols. This meant people were at serious risk of avoidable harm associated with untreated constipation.