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Coote Lane Residential Home Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 14 July 2021

About the service

Coote Lane Residential Home is a residential care home providing personal and nursing care to 17 people aged 65 and over at the time of the inspection. The service can support up to 24 people.

People’s experience of using this service and what we found

Some care plans lacked some information related to people’s individual needs and behaviours. The auditing processes in place did not identify the concerns we found. A new management team had recently been employed to lead the staff and manage the home. Staff told us positive changes had taken place and they were updated on planned future improvements. The management team worked in partnership with a variety of agencies to ensure people's health and social needs were met. Onsite face to face visits by families had commenced to promote people’s wellbeing.

Not all staff followed good practice guidance and company policy. They travelled to and from work in their uniforms, rather than getting changed when at the care home. We have made a recommendation about infection prevention. Medicines were managed safely by trained staff and people received their medicines as prescribed. The home was very clean and used infection control measures to reduce the risk of COVID-19. Staff were aware of individual risks to people and were knowledgeable about how to safeguard people from abuse. Staff had safe recruitment checks before providing care.

The provider ensured staff received training that met people's needs. Feedback showed people were happy with meals and the choice and quantity of food provided throughout the day. One person said, "[The food] its very good. Really tasty." People received support with their healthcare needs. The environment was maintained to meet people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. We observed people were treated with compassion and kindness. People praised the way staff treated them with respect, maintained their dignity and promoted their day to day choices.

How to communicate effectively was recorded in care plans and staff were observed taking time to listen and respond appropriately to people. Activities were available for people to participate in. People were aware of how to raise any concerns should they have any complaints. When required, people were supported with their end of life needs.

Rating at last inspection and update:

The last rating for this service was inadequate (published 25 August 2020) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of all but one of the regulations.

This service has been in Special Measures since 25 August 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvement. Please see the Well-led section of this full report. The provider has taken action to lessen the risks identified during this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Coote Lane Residential Home on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified one breach in relation to good governance and the recording and auditing of information.

Please see the action we have told the provider to take at the end of this report.

Since the last inspection we recognised that the provider had failed to notify the commission without delay of an incident that occurred at Coote Lane Residential Home. This was a breach of regulation. Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 14 July 2021

The service was not always safe.

Details are in our safe findings below.


Requires improvement

Updated 14 July 2021

The service was not always effective.

Details are in our effective findings below.



Updated 14 July 2021

The service was caring.

Details are in our caring findings below.



Updated 14 July 2021

The service was responsive.

Details are in our responsive findings below.


Requires improvement

Updated 14 July 2021

The service was not always well-led.

Details are in our well-Led findings below.