Coppice Lea

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance of the service.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Some people said they knew who the registered manager was. However, one person told us, “You would have to ask especially to see the manager. They don’t come by and say hello. You don’t really see the senior staff here, especially being upstairs.” Relatives’ comments included, “They don’t introduce themself as the manager but then we have not introduced ourselves. There is a new deputy manager but we haven’t seen [them] yet”, “I’m not so keen on the management here” and “[Registered manager] is very nice.”

The management team told us they ensured the staff were valued and promoted people’s individuality, protected their rights and enabled them to thrive. The registered manager stated, “We have core values that everyone is expected to go by. This includes respecting each other and the residents. Integrity, putting our hands up when things don’t go right. We have empathy, in relation to staff, people and colleagues.” The regional manager added, “[Registered manager] has encompassed the company values and how the team is working. [They are] very good at evidencing the good work that happens here. The focus is resident-led now. The residents and relatives are encouraged to speak up.”

Staff told us there was a good and positive culture within the home where people and staff had a good rapport, and the atmosphere was one of respect and care. A member of staff told us, “I am able to make suggestions and have discussions if I have any issues and I feel listened to. And usually we get feedback.”

The provider set a culture that valued reflection, learning and improvement. The registered manager effectively used staff supervision and regular team meetings as a platform for staff to raise any concerns and an opportunity to share their views and opinions.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager had experience of working in health and social care. They had been in post for 11 months and were keen on developing the home in order to benefit people and the staff team. They told us, “The home is a lovely environment and the staff are kind. There were some improvements to make. There have been a couple of changes within the team. Some things had to be changed.”

Staff found the management team to be visible and supportive. The registered manager was an experienced leader who was respected by the staff. A staff member told us, “[Registered manager] is approachable and listens to the staff and I feel confident in expressing my concerns with [them].”

There were regular team meetings and management meetings where a range of subjects were discussed and information was shared. A staff member told us, “Staff meetings are held monthly, we also have daily meetings at 11am to discuss any concerns and updates. I do attend when I am around and I think they are useful as we do make changes based on the information provided during meetings.”

In addition to team meetings, there were daily handover meetings to discuss important information, and any risks to service delivery. There were processes to support managers and senior staff in meeting their responsibilities.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People were given information when they moved to the home about how to raise a concern and said they knew how to make a complaint. The registered manager told us, “We have monthly meetings and my door is always open. I walk around the building several times a day to chat to staff and residents. Residents come to the meetings. I communicate by emails with relatives to keep them informed about anything they need to know.”

Staff said they knew about the provider’s whistleblowing policy and would not hesitate to use this to benefit staff and people living at the home. A staff member told us, “I’ve seen the whistleblowing procedure put up around the home. It means that I can always raise concerns about poor practice safely. I haven’t had to do that before but I would feel able to do it if it were the case. I would go to my manager first and the senior staff or to external agencies.”

The provider had processes in place to support staff to speak up. This included supervision meetings, handover meetings, staff meetings and a whistleblowing policy. Staff had also received training in safeguarding to reinforce their understanding and their responsibility to speak up. The registered manager told us, “We have one to one chats with carers where they can raise anything they need to.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they enjoyed working in a diverse team. However, all staff had a good understanding of the English language and there were no language barriers.

The provider had policies to promote equality, diversity and inclusion and to protect staff from discrimination and harassment. The registered manager told us, “It’s important to understand staff’s needs. For example, a former member of staff’s religion requested they needed to spend time praying and could not touch certain foods. Their needs were taken seriously and met.”

The organisation had a working group which included the subject of diversity. In some of the provider’s new homes, they were creating prayer rooms. The provider’s yearly staff survey included questions on how they could improve in terms of diversity and equality.

Staff who had healthcare needs were supported appropriately. The registered manager told her they met with them regularly to establish how they were feeling and how they could meet their needs within the workplace.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had monitoring systems in place. However, these had not always been effective and had failed to identify and address the concerns we found during our inspection.

People did not always receive their medicines safely and as prescribed. Medicines audits had either not identified shortfalls or when shortfalls had been identified, no action had been taken. This put people at risk of not having their pain and healthcare conditions effectively managed.

Processes to help ensure that risks to people were assessed and mitigated were not always effective and there had been repeated incidents whereby a person had left the building unsupervised. Some of the doors with access to the garden were easily opened and the provider had not taken appropriate steps to reduce this risk. This put people at increased risk of harm.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff told us they worked well with healthcare professionals to ensure people’s needs were met. The registered manager confirmed they had a good working relationship with a range of external professionals. They said, “We work with the GP surgery. The doctor comes in weekly. We work with the speech and language team for people who have problems with swallowing. The chiropodist comes in regularly. We have a nurse coming in every month for a catch up to see what’s gone well or not so well and if the team need support.”

The provider had systems and processes to ensure people’s needs were reviewed with external professionals. The provider listened to feedback from them and where a need was identified, amended their policies and procedures to promote effective communication and partnership working.

The registered manager told us they had put in place an information pack for each person. This was to prevent communication being lost when a person was admitted to hospital. They ensured this was sent with the person so the hospital staff had the information straight away. The registered manager told us, “This might reduce the time the person spends in the corridors, and ensures the staff understand the person’s needs.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Although most people said they were consulted during meetings, reviews or regular conversation, to find out if they had any concerns or requests, one person told us, “I’m not aware of any meetings. I’m not involved or invited. No-one comes round to ask if things are OK.” Relatives said they were aware and invited to meetings. They told us, “There are meetings where they invite the relatives; likewise, there are those for residents. I think their communication is good” and “Meetings are useful. I make suggestions if improvements are needed. You have to be realistic with nursing homes or social care in general. It is not perfect but the carers are kind and that is the most important area.”

The registered manager told us they listened to people’s feedback and made improvements. They explained how, following an incident, they had looked at processes and improved their initial assessments of people to ensure they put the right support in place straight away. They told us, “There is a significant improvement based on people’s feedback and relatives’ feedback. People had complained about the food, so we organised meetings with family and people to discuss this and made the necessary improvements.”

Staff told us the managers were always aiming to make improvements to the service to benefit people, and they enjoyed being part of this and felt consulted and involved.