CQC report explained · a nursing home
What the CQC found at Cooperscroft Care Home
Rated Outstanding: inspectors found the home performing exceptionally well.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Staffing, medicines, infection control and risk management were generally good, although inspectors found a few omissions in risk and medicines records that were addressed immediately.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward.
- Responsive?
- Outstanding
- This key question was not inspected during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Outstanding
- Inspectors found exceptional leadership, a strong person-centred culture, robust quality checks and excellent involvement of people, relatives and staff.
What inspectors found, January 2024
Rated Outstanding overall; inspectors found exceptionally well-led, person-centred care, while the safe rating was Good and a few records needed immediate correction.
This was an unannounced focused inspection. Inspectors visited on 13 and 14 November 2023, with inspection activity continuing until 29 November. They spoke with people, relatives, staff and outside professionals. They also observed care and medicines administration and checked care records, medicines records, training and quality checks.
The home was rated Good for Safe. People told inspectors they felt safe. There were enough staff, medicines were generally given safely, infection control was good, and risks, incidents and safeguarding concerns were managed well. A small number of gaps in risk assessments and medicines information were corrected during the inspection.
The home was rated Outstanding for Well-led. Inspectors found an exceptionally positive and person-centred culture. Managers were visible and approachable, listened to people and relatives, and used feedback and detailed audits to improve care. Staff were supported with training, development and wellbeing initiatives.
The overall rating changed from Good to Outstanding. However, this inspection only assessed Safe and Well-led. The ratings for Effective, Caring and Responsive were carried forward from the last comprehensive inspection in 2018.
People felt safe
People and relatives told inspectors they felt safe. Staff understood safeguarding responsibilities and acted on concerns appropriately.
“People and their relatives told us they felt safe.” from the report
Enough staff
Inspectors found enough staff to meet people's needs safely. Call bells were answered quickly and people did not appear to wait long for support.
“On the day of our inspection site visit, there were enough staff to support people safely.” from the report
Person-centred culture
The home supported people to maintain independence, take positive risks and pursue their wishes and interests. People were also involved in the running of the home.
“There was an exceptionally positive, open and inclusive culture at the service.” from the report
Strong leadership
Managers were visible and approachable. The home used audits, feedback and action plans to identify improvements and share learning.
“The provider had created an exceptional learning culture at the service which continuously improved the care people received.” from the report
Staff development and wellbeing
Staff had access to training, development opportunities and wellbeing support. Their skills and interests were used to improve care.
“There was a strong emphasis placed on the importance of staff health and wellbeing” from the report
Some risk assessments had gaps
minorInspectors found omissions in a very small number of risk assessments. The registered manager corrected these immediately.
“Although we identified omissions in the content of a very small number of these assessments during the inspection, the registered manager took immediate action to address these.” from the report
Some medicines risk information was missing
needs fixingSeveral people prescribed paraffin-containing creams did not have a fire risk assessment, and one person's care plan did not include information about food interactions with warfarin. The provider addressed these issues immediately.
“However, several people prescribed paraffin-containing emollients did not have a fire risk assessment.” from the report
- 01How do you check that every person's risk assessment is complete and kept up to date?
- 02What fire safety advice and assessments are in place for people using paraffin-containing emollients?
- 03How do you record and review food interactions and other risks for medicines such as warfarin?
- 04What were the ratings for Effective, Caring and Responsive at the last comprehensive inspection, and when will these areas next be reviewed?
- 05How will my relative and our family be involved in care reviews, feedback and decisions about positive risk-taking?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried forward from the last comprehensive inspection in 2018. This explanation was written from the published report of 9 January 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2018
Rated Good, with Outstanding responsive care; inspectors found safe, kind support and improvements since the last inspection.
Inspectors visited on 26 April, 2 May and 14 May 2018. They spoke with people living in the home, visitors and staff. They observed care and activities, and checked care records and other management records.
The home was rated Good overall. Safe, Effective, Caring and Well-led were rated Good. Responsive was rated Outstanding. Inspectors found no evidence of serious risks or concerns, and said improvements had enhanced people's experience of care.
People were generally supported by enough trained staff. Their medicines, risks, food, drink and healthcare were managed well. Care was usually kind and personalised, with particularly strong activities, social support and end of life care.
There were some shortfalls. One recruitment file did not include full checks, some medicine records were marked with dots rather than signatures, and staff practice was not always consistent. The provider took action during or shortly after the inspection.
Personalised activities
Activities were based on people's interests and abilities. Staff also found ways to involve people who could not join group activities or outings.
“People had access to a comprehensive range of activities which were based on people's individual needs and choices.” from the report
Support against isolation
Staff worked hard to help people stay socially connected. Activities, outings and contact with children and animals helped people feel involved.
“Staff were committed to ensuring that people's social needs were met to help them avoid isolation.” from the report
End of life care
People nearing the end of life and their families received compassionate support. Plans recorded people's wishes, including whether they wanted to remain at the home.
“People receiving end of life care and their families were treated with exceptional care and compassion.” from the report
Respect and dignity
Staff usually treated people as individuals and protected their privacy. People were supported to remain independent and make decisions about their care.
“There was a strong culture within the service of treating people with dignity, respect and supporting people to remain as independent as possible.” from the report
Improved safety
The home had addressed the problems found in its previous Safe rating. Risk assessments and electronic care plans helped staff respond to people's current needs.
“At this inspection we found the required improvements had been made and have rated the service as Good.” from the report
Incomplete recruitment checks
needs fixingOne recruitment file had gaps in employment history that had not been explored and contained only one reference. The provider took immediate action to correct this and review recruitment processes.
“However one staff recruitment file had gaps in the employment history that had not been explored at interview and provided only one reference.” from the report
Medicine records
needs fixingStaff had not always signed the medicine administration records and had used dots instead. Inspectors confirmed that medicines had been given, but routine audits had not identified the problem.
“However, staff had not always signed the MAR but had 'dotted' the entry.” from the report
Inconsistent personal care
needs fixingSome feedback suggested that staff did not always attend to small but important needs. Concerns included positioning, drinks and agency staff not knowing how to support a person properly.
“However, we were also told that at times staff could be less person centred in their approach, and the consistency around attending to little things was not always followed.” from the report
Dementia-friendly environment
minorThe building was accessible and spacious, but inspectors said more appropriate signs and reminiscence items were needed for people living with dementia. Redecoration and other work were planned.
“However, more work was needed to ensure there was more appropriate signage and reminiscence items around for people who lived with dementia.” from the report
Incident handovers
needs fixingSome incidents were not always passed to management for investigation. The manager changed the daily handover process during the inspection.
“However, we spoke with the provider on the day of the inspection and showed them where incidents within the home were not always handed over to management for investigation.” from the report
- 01How do you now check that every medicine administration record is signed correctly?
- 02What checks are completed before new staff, including agency staff, start supporting residents?
- 03How do you make sure agency staff understand each person's positioning, moving and personal care needs?
- 04What changes were made to daily handovers so that every incident is reviewed by management?
- 05What improvements have been made to signage and reminiscence items for people living with dementia?
This inspection assessed all five key questions; the report says the overall rating stayed the same, while the previous Safe rating of Requires Improvement improved to Good. This explanation was written from the published report of 30 August 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Cooperscroft Care Home
3 rated inspections over 8 years: the service has improved, from Good to Outstanding.
- January 2024Outstandingcurrent ratingup from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Outstanding
- August 2018Goodstayed GoodSafe: GoodWell-led: Good
- May 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015
Registered with the Care Quality Commission on 3 September 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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