Coppice Lodge

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 requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. They demonstrated a positive learning culture where staff learned from incidents and feedback to drive improvement. Staff completed incident reports, which the registered manager reviewed and analysed to identify actions, patterns and trends to reduce the risk of reoccurrence. The service follows a complaints policy, and when it received one complaint, the registered manager discussed it at a staff meeting and used it as a learning opportunity, focusing on how practice could be improved. The registered manager understood their responsibilities under the duty of candour to be open and transparent when things went wrong.

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. Staff supported people to experience introductory visits before admission, which helped them become familiar with the environment and staff and supported a smoother transition. The registered manager completed pre-admission assessments and had undertaken training to ensure these were carried out effectively. They gathered detailed information about each person’s needs, preferences, and background and actively considered compatibility with others using the service. This process enabled the registered manager to make informed decisions and only offer placements where the service could safely and appropriately 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. Staff received safeguarding training and demonstrated a clear understanding of the different types of abuse and how to raise concerns appropriately. People using the service appeared relaxed in the company of staff. They told us they felt confident any concerns raised would be taken seriously and addressed by the registered manager. Staff described an open and transparent culture within the service, where the registered manager actively encouraged open communication and supported staff to speak up and share concerns.
We checked whether the service was working within the principles of the Mental Capacity Act 2005 (MCA) and how they managed Deprivation of Liberty Safeguards (DoLS) within the service. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. We found people who did not have the capacity to agree to their care and treatment had the appropriate legal safeguards in place.
 

The provider worked with people to understand and manage risks by thinking holistically, taking into account their physical and mental health, safety, and the environments in which they lived and accessed their community. For example, risks to people accessing the community were assessed and strategies put in place to support the person and others in the event the person became distressed.
Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Records showed when individual risks were identified, these were discussed with the person and agreed measures to reduce harm while promoting independence. For example, 1 person required support to maintain their safety when out in the community. Care records described the identified risks and the actions staff needed to take. Staff followed clear strategies to support people to take positive risks, including guidance on how to respond if someone became distressed while out in the community, which helped staff support people safely and consistently. Staff knew people well and were able to identify changes in their presentation to enable them to respond proactively.
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The premises had recently undergone refurbishment. The environment was clean, tidy and homely and was maintained to a good standard. The provider had processes in place to ensure staff carried out routine safety checks, including window restrictors, hot water temperature monitoring, and legionella testing. During our visit, we identified that wardrobes had not been secured to walls to prevent the risk of serious or fatal injury from tipping. We discussed this with the registered manager, who told us they had already identified this through their own audits. When we returned for the second day of the inspection, the registered manager had spoken with each person to gain consent, and wardrobes had been secured. We found suitable arrangements were in place to manage fire safety. Staff carried out regular fire drills, and each person had a personal emergency evacuation plan (PEEP) in place.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. They followed safe recruitment practices and had systems in place to ensure staff were suitable to work at the service. The provider completed all relevant pre-employment checks, including Disclosure and Barring Service (DBS) checks, to support safer recruitment decisions. Staff told us they received a thorough induction into the service. The registered manager took an active role in welcoming new staff, introducing them to the service and company, and ensuring they completed mandatory training and shadowed experienced staff before working independently. We reviewed training records and found staff had completed training appropriate to their roles, with training compliance at 100%. The service used a dependency tool to calculate staffing levels, and during our visit we observed there were enough staff available to support people safely and meet their needs.

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. The service followed effective infection prevention and control practices in line with best practice. Staff had access to appropriate personal protective equipment (PPE) and used a colour-coded system to reduce the risk of cross-contamination. Staff labelled and stored food items correctly to promote food safety and hygiene. The provider also had an infection prevention and control policy in place, which reflected current best practice and guided staff on maintaining a safe and hygienic environment. Staff carried out regular audits to ensure compliance was maintained.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened. People received their medicines as prescribed from staff who were trained and assessed as competent. The registered manager regularly audited medicines management to ensure safe and effective practice. When errors or discrepancies were identified, the registered manager fully investigated these and took appropriate action to reduce the risk of reoccurrence. Any lessons learned were discussed at staff meetings. Staff and leaders implemented recognised guidance to ensure people did not receive medicines when they were not needed. STOMP (Stopping the Over Medication of People with a Learning Disability, Autism or Both), is a national initiative which promotes the regular review of psychotropic medicines and ensures these are only used where clinically appropriate and in people’s best interests.