Coppice Lea

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 good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

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.

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.

People told us they were happy living at the home and felt safe and well cared for. One person said, “I am happy here, they are good.” A relative echoed this and said, “I do have peace of mind with my relative being here, mainly because the staff are so caring.”

Managers and staff told us incidents and accidents, safeguarding concerns and complaints were recorded on their system. These were reviewed, discussed and analysed to determine any underlying causes or trends and identify any actions required to improve the service.

Staff told us regular meetings were used to share information about any incidents along with any learning and we saw evidence of this. Staff knew how to report and document any incidents or accidents. Lessons were learned 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.

People told us they felt safe living at Coppice Lea. They told us the staff were available if they needed support. Relatives stated they were informed when their family members required support or treatment from different agencies.

The staff team and managers told us they worked well with other professionals to ensure continuity of care, including when people moved between different services or required temporary stays in hospital. Healthcare professionals told us they had a good working relationship with the service and communication was good.

Staff told us they were happy working at the home and felt supported and listened to. They said they received training that equipped them to do their job well and care for people who used the service. A staff member stated, “I feel supported in my role. I feel confident to ask questions when I am not sure about things and also, I feel supported with my training.”

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.

People told us that in general they felt safe and protected from abuse. One person told us, “I have been here a few weeks now and I like it.” A relative added, “Yes, it is safe – I never worry about [family member] being here.”

Records showed that safeguarding concerns were reported appropriately. The service was working alongside the local authority safeguarding team to ensure processes to manage risks were in place and monitored. Staff received safeguarding training and demonstrated an understanding of the different types of safeguarding, reporting procedures and the whistle-blowing policy.

The provider understood their responsibilities under the Mental Capacity Act 2005 in ensuring Deprivation of Liberty safeguards (DoLS) applications were submitted as required.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Most people said staff knew their needs and met these safely. One person told us, “They look after you well. They tell me off if I try to get to the toilet on my own – I have fallen before. I have to use the bell and wait for them to help me.”

However, processes to help ensure risks to people were assessed and mitigated had not always been effective. There were several doors on the ground floor which could be easily opened by a person, and although these were alarmed, there was a high risk a person would be out of the building before a staff member could reach them.

For example, one person living with dementia was at known risk of going out via these doors and there had been a high number of incidents where this had happened. The registered manager told us they had not been made aware the person was at risk of absconding during the initial assessment, and they would not have accepted them if they had known this. The provider had subsequently given notice for the person to leave. No other solution had been sought to reduce this risk and meet the person’s needs.

Other risks were managed well. For example, one person was at high risk of malnutrition. We saw they had been reviewed by a dietician, their weight was checked frequently, and they were being offered fortified food.

Another person was at high risk of developing a pressure ulcer. Their care plan stated how staff could support them to reposition themselves in bed and to check regularly for areas at risk. The person was monitored closely and was supplied with pressure relieving equipment which was regularly checked.

Incidents and accidents were recorded and contained details such as a description of events leading up to the incident, action and response and post incident analysis. Each report also highlighted what has been put in place to prevent re-occurrence. Following the incident, an action plan was put in place and care plans and risk assessments were reviewed.

Care plans contained details to inform staff how best to support people with complex health conditions such as diabetes or Parkinson’s disease. Care plans contained details on how to recognise signs people were becoming unwell and what action to take. This meant the staff would be able to take appropriate action should they noticed people displaying symptoms.

Personal emergency evacuation plans were in place for each person. These contained detailed information about each person and the support they required to safely evacuate the building in the event of a fire or other emergency.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Although people were mostly supported in a safe and well-maintained environment that met their needs, we identified a risk of people leaving the building unsupervised because some of the ground floor doors could easily be opened. This is highlighted in a previous section of this report. Although there were systems in place to monitor and regularly check the safety and upkeep of the premises, this concern had not been identified and addressed. This was discussed during our feedback to the provider.

The management team and staff worked together to help ensure faulty equipment or trip hazards were identified and addressed promptly. The maintenance person had been absent for some time, but we saw that most safety checks were completed daily and weekly in all areas of the home to ensure safe systems were in place. These included water temperatures, fire safety checks and kitchen equipment.

Equipment used to support people was suitable, well maintained and stored securely. The provider had an up-to-date emergency plan in place to help ensure people were supported in the event of an emergency.

People’s bedrooms were personalised with photographs and items belonging to them. There was signage around the home, and objects and pictures to help people with reminiscence.

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.

Most people thought there were enough staff to support them and meet their needs. One relative told us, “You do see carers around so we guess there are enough staff. They seem to know what they are doing. They always make sure that there are two [staff] to use the hoist and it is all done smoothly.” However, one person stated, “It might be me being fussy but I get the feeling that they are always in a rush. I’d like to have a chat sometimes, but I don’t think they have the time – it could be because of staffing levels – I couldn’t say for sure.” We raised this with the registered manager who told us they would address this without delay.

The provider used a dependency tool to help ensure there were always enough staff to meet people’s needs.

The provider carried out checks on the suitability of staff before they started working at the service. Systems in place included checks on new staff’s identity, eligibility to work in the United Kingdom and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

The company employed sponsored employees. We saw that all relevant checks had been undertaken such as documentation from UK Visas and Immigration, certificate of sponsorship details, UK pre-departure tuberculosis detection programme and police clearance from people’s country of origin, as well as a DBS.

Staff told us they were happy working at the home, felt supported and listened to. They said they received training that equipped them to do their job well and care for people who used the service.

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.

People told us they felt safe from the risk of infection because premises and equipment were kept clean and hygienic, and relatives confirmed they did not have any issues with cleanliness of the service.

During the morning, we detected a slight malodour on the first floor. However, we observed the cleaning staff working in all areas of the home, and the malodour had disappeared by the afternoon.

Cleaning staff followed a cleaning schedule and used appropriate personal protective equipment (PPE). Care staff wore PPE when supporting people to help protect people from cross infection. A member of staff told us, “I’ve had training regarding infection control. I wash my hands regularly, use PPE, ensure the equipment is clean and follow the guidance to stop infections spreading.”

Appropriate systems were in place in relation to infection control. The provider ensured staff had access to PPE and were trained in the use of this. The provider’s infection prevention and control policy was up to date. Information about the risk of infection was shared appropriately with people using the service and visitors. The managers and senior staff carried out audits to ensure standards of cleanliness were good.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

People told us they received their medicines safely and as prescribed. However, we found some concerns in relation to medicines management.

People did not always receive their medicines at the required time. One person was prescribed pain medicine to be given at specific times daily. However, we found multiple occasions when this medicine had been delayed for over 3 hours. We also found another medicine that had not been given at the time prescribed twice within a 2 week period. This put people at risk of not having their pain effectively managed.

A second person’s medicines stated they needed to be used within a certain timeframe as it would spoil after this timeframe and become less effective. However, as the staff had not recorded a date of opening, we could not be sure this instruction had been followed correctly. A July audit had identified that some medicines did not have opening dates. However, this had not been addressed and had continued to happen. For the same person, an ointment had been discontinued on 9 September 2025, but this was still in the medicines trolley.

The label on a third person’s medicine stated to discard this after one month of opening. However, we saw the staff had continued to administer this on 4 occasions 2 months after the date of opening. Although this had been identified in an audit in August, no action had been taken.

Records of medicines stock were not always correct, which meant we could not be sure people were receiving their medicines correctly. We found the electronic system had recorded a person had 27 tablets of a medicine left in stock, but we found 30 remained. In addition, we found a person was not given 2 doses of their prescribed pain-relieving medicine on one occasion.

Some people were prescribed thickeners to add to their drinks where they were at risk of choking. We saw none of the people prescribed thickeners had electronic medicines administration record (eMAR) charts in place to record the administration of this. This meant there was no record when this was administered.

Staff did not fully demonstrate they knew the correct process for the destruction of all medicines. This meant anyone could easily access undestroyed tablets.

Where people were prescribed ‘as required’ medicines, we saw there were protocols in place to inform staff about the medicine and how to administer this in line with the prescriber’s instructions and the person’s needs and preferences. We saw some protocols were not always completed appropriately on the electronic system. This was fed back to the nurse in charge.

Medicines audits were undertaken but were ineffective because they either did not identify concerns or did not take appropriate action when shortfalls were identified. For example, an audit completed by a nurse in August found a number of concerns. These had not been resolved by the time of our inspection.

Medicines reviews were carried out by the local GP. There was a process to report and investigate errors and incidents. There was a process in place to receive and act on medicines alerts. Medicines were stored securely and at the required temperatures. Staff received training and were competency assessed to handle medicines safely.

The provider had recently transitioned to an electronic medicines administration record system and all authorised staff had received training in this.