Coplands Nursing Home

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. Based on the findings of this assessment the rating for this key question has changed from good to requires improvement. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed. This is because medicine administration was not managed safely in line with best practice. There were issues with the services response to concerns and there were gaps identified in some staff knowledge relating to safeguarding protocols.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Managers and staff told us incidents and accidents were recorded on the system, this included any safeguarding concerns or complaints. These were analysed and reviewed to determine any underlying causes and identify any action or improvements. Staff told us that team meetings were used to share information about any incidents along with any learning. Though we saw evidence of lessons learned and the service responding to concerns about safety, they did not always have a proactive and positive culture of safety. Feedback from some relatives indicate they did not always listen to concerns and did not always respond efficiently.

Care plans and risk management plans were in place for everyone living at the care home. Managers informed us they planned and organised care and support with people, together with partners and relatives in ways that ensured continuity, including when people moved between different services.

The provider had clear safeguarding and staff whistleblowing policies and procedures which were kept up to date, reflected relevant legislation and were easy for staff to access. However, the service 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. For example, we looked at 2 internal investigations carried out by the service. One internal investigation was from an allegation of abuse in October 2024, which involved allegations of abuse against a staff member toward a person who resides at the service. There were inconsistencies in the findings, and concerns were further underscored by the local authority regarding the management of this investigation and its findings. We requested for immediate assurances from the registered manager who confirmed gross misconduct was not upheld, and enhanced supervision, monitoring and additional training and development had been put in place.

According to the training matrix, safeguarding adults training had 100% staff compliance. Some staff we spoke with demonstrated good knowledge of safeguarding, however some staff had a lack of understanding regarding safeguarding protocols, and what being safe meant. Some staff we spoke with were unaware of the external reporting processes for safeguarding concerns.

Some people and relatives we spoke with told us the service worked with people to understand and manage risks by thinking holistically. However, some relatives told us staff did not always respond to risks efficiently, they reported delays in the services response to people’s deteriorating health needs.

The service had established systems in place for the recording and monitoring of accidents and incidents. People’s care plans and risk assessments we reviewed holistically captured people’s needs, preferences and choices. Management told us the service had clinical ‘flash’ meetings daily to discuss any updates, emerging risk and changes in people’s care and support needs. Team meetings occurred quarterly, we saw evidence in team meeting minutes of emerging risk, concerns and areas of improvement being discussed. We also saw positive reflections in team meeting minutes allowing staff members to share and discuss what has gone well. A structured handover is conducted at the beginning and end of every shift. We reviewed handover documents, which were clear and provided essential information regarding the people they support, as well as any changes that may have occurred.

The service did not always detect and control potential risks in the care environment. For example, we identified with risk management practices during the environment check of the service. A shower room for people appeared to be simultaneously used for other purposes. For example, clean bed linens were stored on an open shelf as you enter the shower room and opposite was dirty laundry which contained soiled materials, there was strong odour coming from it. This arrangement was not appropriate and poses health risks with the presence of waste and soiled linens alongside a space designed for personal hygiene. Management took immediate action to address this on the day of assessment.

The service had an up-to-date fire risk assessment in place for the building. The environment had adaptations and reasonable adjustments in place to meet people’s individual needs. We looked at the maintenance records and procedures, including legionella. All logs were completed regularly and very thorough. All emergency work that required contractors was logged with head office immediately. However,

Some people who reside at the service told us about delays in staff responding to call bells, leading to feelings of frustration. During the day of assessment, we tested call bells in several bedrooms, and they were found to be in good working order.

We observed staff were visibly present throughout our on-site visit. Staff demonstrated good engagement with the people they support and were attentive to their needs, which included supporting with eating and drinking and safe moving and handling practices.

Staff we spoke with told us management made sure there were enough skilled and experienced staff, and they received effective support, supervision and development. A staff member told us “Management is very approachable, and they fully support my development in this role.” Staff told us the care team worked well together to provide safe care that met people’s needs. The service consisted of a clinical team, care team, hospitality team, activities coordinators and a staff member responsible for the maintenance of the building.

The service supported people who had commissioned enhanced observations in place due to their individual care and support needs. We observed people who required one-to-one support with their allocated carer during the site visit.

We reviewed duty rota over a 4-week period. We noted that 1 registered nurse is responsible for overseeing a unit of 26 people during the night, with 1 senior care staff support. We brought this to the attention of the deputy manager who informed us the level of care needs during the night was low, and therefore this staffing level was sufficient.

We checked 3 staff recruitment files and saw that all appropriate processes and checks were in place. The service conducted enhanced disclosure and barring service (DBS) checks., which provided information including details about convictions and cautions held on the Police National Computer. The information helped the service make safer recruitment decisions.

The service had mandatory training and induction shadowing workbook for all new starters. New starters were assigned to an experienced mentor, who was accountable for ensuring the pathway was completed by new staff members and signed off. Training records showed that staff received ongoing training that was appropriate for their role. Training records for the service indicated 100% staff training compliance in all mandatory areas including Manuel Handling, Infection Control and First Aid.

Supervision records showed staff had regular supervision meetings with the registered manager to support them in their role and to identify any further training or learning they might need. There were systems in place for the service to identify and monitor staff training and supervision requirements and ensure it remained relevant and up to date.

Managers and staff told us they had received up to date infection control training. Staff and management told us that the service was regularly cleaned. Staff checked, maintained, and cleaned equipment daily, this was reflected in cleaning records.

We saw evidence of good practice regarding prompts for staff to record when patches are applied and daily recordings, however, staff did not ensure the rotation of patches and injection sites to minimise the risk of side effects. For example, risk of developing lumps at injection site. We found that PRN protocols were not always person centred, they were updated every 3 months but were completed with generic template examples and not person specific information. We also found that not all PRN protocols were being followed, and in some instances, PRN protocols were not uploaded correctly onto the EMAR system. Furthermore, in one record, we saw evidence of a best interest decision made to give medicines covertly, and agreement signed by the relevant professionals. However, the information did not contain manufacturer or pharmacist instructions on how to safely disguise the medicine in food and drink. We asked the provider for immediate assurances, and they provided evidence of immediate actions taken and reinforced staff training and enhanced oversight of medication processes. The storage and monitoring of medication including controlled drugs was managed safely. Management of time sensitive medicines was effective, and staff were able to tell us how they prioritised these medicines to ensure they were given promptly.