Coppice House

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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.

The service was in breach of legal regulation in relation to good governance at the service..

This service scored 57 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service did not always take timely action in response to risks and concerns or prioritise safe good quality care and improvements were not always sustained. We saw actions staff were expected to implement, such as monitoring people’s bowel movements who were at risk of constipation and recording fluid intake, but these were not consistent. Outside health professionals had provided training for staff to help them understand some health risks associated with people with a learning disability and autistic people who live with a learning disability and/or autism. The learning from this was not applied consistently across the service.

We did not identify a consistent culture of learning and improvement. Actions identified from audits were not completed without delay, some action had been in progress for a long time and others re-identified without further escalation.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Whilst the manager was supported weekly by visits to the home by the provider, these visits had not identified some of the areas of concern we found through observations during the assessment, for example, limited interaction with people and restrictions around access to drinks for all people.

However, relative feedback was positive about how staff and management treated people and themselves.

One relative told us, “they’re so dedicated, they really listened and it took a lot of work from their team and now they go swimming once a week in their car.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had policies and processes in place to support staff in raising concerns. They also provided staff with information about how concerns can be escalated.

Staff told us they felt listened to when raising concerns to the service’s management team. A staff member told us, “Yes, I can feedback of course, and we have a speak up policy where we can raise any concerns or if we feel we are not being treated well. If our direct managers do not take it seriously or handle this issue, there is a dedicated number for this.”

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.

People were being supported by a diverse staff team. Staff told us they felt supported and did not share any concerns about the way they were treated. Policies and procedures were in place to support staff in their role.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have an effective system in place to monitor the quality of care delivered and drive improvements. Whilst the provider’s audits and checks identified areas of improvement, actions were not effectively followed up or addressed. These included areas such as incident and accident analysis, review of care documentation, risk assessment, restrictive practice, medicines, health and safety, the environment people lived-in, person-centred care and oversight of staff training and recruitment. These concerns and failure to take timely actions in relation to these placed people at prolonged risk of increased harm.

Team meeting minutes reflected ongoing concerns with staff culture at the service. Similar themes were raised at meetings between December 2026 and April 2026, regarding staff supporting people appropriately, care documentation, staff leaving shift early and refusing to complete tasks. Similarly, staff raised with the manager they were short staffed and when this happened people were missing out on their regular activities.

We found one person’s bedroom did not reflect the person’s individual needs; the person had complex needs and required a different approach to support them with their bedroom. This person’s needs were well established at the service and well known by different parts of the organisation such as operations and the positive behaviour support team however it took for an outside professional to visit the service earlier this year before a plan of action was put in place. At the time of our assessment the person’s room remained the same although we were told new furniture had been ordered to trial, their toilet was fixed and secured during our visit.

The provider had yet to roll out part 2 of the required mandatory learning disability and autism training. This requirement came into effect in 2022. As a specialist provider they are required to ensure staff are suitably trained to interact and support people with a learning disability and autistic people.The provider told us there was a plan for this training be rolled out across the organisation in June 2026.

However relative feedback about the service and how it was run was positive. One relative told us

“It’s impressive as a service with good management because it’s very well run, and I’ve seen changes and improvements in the accommodation, outings and activities, cooking their meals fresh on site, although they have takeaway sometimes. And they eat a pub meal and the restaurants where they go to are where the staff know the clients.”

The garden is big and beautiful, and they do barbecues.”. Another relative said “this really was the best fit we could find at the 11th hour, and we’re very happy with it.”

Partnerships and communiti

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.

There was evidence of joint working with professionals, accessing health support for people when required and referrals being made.

People were accessing the surrounding community and taking part in activities; some being supported with wider and more person-centred engagement than others.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

They did not encourage creative ways of delivering equality of experience, outcomes and quality of life for all people. The provider had not effectively used their own auditing processes. Regular input at the service from the provider had not recognised concerns, and the provider had not used their visits to support the manager and staff to implement change where needed in a timely way. Provider records we viewed showed provider visits and actions were required, in some cases these were not followed up or signed off as completed.

The provider was receptive to the concerns we raised following our assessment. The provider put in a robust plan of action and started implementing this immediately to minimise the impact to people’s safety.