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The provider of this service changed - see old profile

We are carrying out a review of quality at Coote Lane Residential Home. We will publish a report when our review is complete. Find out more about our inspection reports.


Inspection carried out on 10 July 2020

During an inspection looking at part of the service

About the service

Coote Lane Residential Care Home is a residential care home providing accommodation and personal care for up to 24 people aged 65 and over. There were 17 people living at the service at the time of the inspection. Some of the people lived with dementia and required support with their physical needs.

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

People told us they felt safe and staff were kind and caring. However, our observations showed that people did not always receive safe care and treatment. Staff had not reported safeguarding concerns to safeguarding authorities including repeated and unexplained injuries. People’s safety had been compromised due to the lack of adequate falls reductions measures being put in place. Risks to people were not always reviewed to identify ways to reduce repeat occurrences. People were at risk of harm from equipment and premises that were not inspected and maintained regularly. Risks of the spread of infections were not managed appropriately. People were offered their medicines in a safe manner however; improvements were required to the safe storage of medicines and record keeping.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People told us staff sought their preferences, however, people’s ability to make decisions and to consent to care and treatment had not been assessed. The registered provider had not followed national guidance and best practice to support the effective delivery of care. People were not always supported by staff who had the right competences, induction and supervision to meet their needs. Staff supported people to have access to health professionals and specialist support. People were not offered a variety of choice on their daily meals.

The governance and quality checks in the home did not promote the delivery of safe care and treatment. The registered provider had not established good governance in line with best practice to improve the care delivered and to ensure compliance with regulations. There were no established policies to promote the effective delivery of care. The registered provider had not established robust oversight to support staff on the running of the service and compliance with regulations and to monitor people’s experiences.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for the service under the previous provider was Good, published on 2 November 2018. This is the first inspection of the service under this new provider.

Why we inspected

We received concerns in relation to the management of falls and safeguarding concerns. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.


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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to keeping people safe from preventable harm such as repeated fa