CQC report explained · a residential care home
What the CQC found at Copperdown Residential Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People generally felt safe and medicines were given respectfully, but medicine stock records were not accurate. Staff did not always follow fluid and positioning instructions, and hand sanitising was not always done between personal contact with people.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Caring?
- Good
- This question was not assessed during this focused inspection. The report records positive feedback from people and relatives about the care.
- Responsive?
- Good
- This question was not assessed during this focused inspection. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management checks did not reliably identify problems with medicines, risk assessments or staff records. The inspection found a breach of Regulation 17 because governance systems were not effective enough.
What inspectors found, March 2021
Rated Requires Improvement; inspectors found people generally felt safe and received kind care, but safety checks and management systems were not reliable enough.
This was a focused inspection on 28 January 2021. It followed concerns about people's safety and looked only at Safe and Well-led. The inspector spoke with people, staff, relatives and the manager, observed care, checked records and asked for further information.
People told inspectors they felt safe. Medicines were usually given safely, staff treated people respectfully, and relatives gave very positive feedback about the care. However, medicine stock records were inaccurate, some creams were not dated when opened, and staff did not always follow people's fluid or positioning needs.
The home did not have strong enough checks to find and fix these problems. The inspection found a breach of Regulation 17 on good governance. The overall rating fell from Good to Requires Improvement, while the other question ratings were carried forward from the previous comprehensive inspection.
People felt safe
People told inspectors they felt safe in the home. Safeguarding systems were in place and concerns had been recorded.
“People told us that they felt safe in the service.” from the report
Respectful medicines support
Although medicine stock controls were weak, staff supported people to take medicines respectfully and maintained their dignity.
“Staff supported people to take their medicines in a respectful way.” from the report
Positive family feedback
Relatives were very positive about the care and said the home kept in touch during the pandemic.
“They are like a family to [Person] all the staff are golden.” from the report
Contact after incidents
Accidents and incidents were recorded, and relatives said the home contacted them when something happened.
“Relatives confirmed that the service contacted them if an accident or incident occurred.” from the report
Medicine stock records
seriousThe home could not provide an accurate running total for some medicines. Two of three randomly checked medicine stocks did not match the provider's records.
“The registered manager could not provide documentation of an accurate running total of medication stock that remained in the home.” from the report
Unmet health needs
seriousTwo people's recommended fluid targets had not been met for four weeks, with no guidance on what staff should do. Another person's feet were not elevated as their care plan required.
“There was no escalation guidance to advise staff what to do if the recommended target had not been met.” from the report
Weak management checks
seriousAudits did not identify medicine errors, missing cream opening dates, missing escalation guidance or incomplete employment histories. This led to a breach of Regulation 17.
“The lack of robust governance systems meant that improvements were not always achieved.” from the report
Infection control practice
needs fixingInspectors were not always assured that PPE was being used safely. Staff were seen not sanitising their hands between personal contact with more than one person.
“We saw that staff did not sanitise their hands when having personal contact with more than one person in the lounge area.” from the report
Incomplete employment histories
needs fixingThe home could not always show that it had taken a full employment history for some staff members.
“The registered manager could not always evidence they had taken a full employment history of some staff.” from the report
- 01What has been changed to ensure the stock of as-needed medicines is counted accurately and checked independently?
- 02How are staff now told what to do when a person's recommended fluid target is not met?
- 03How do you check that care plan instructions, such as elevating a person's feet, are followed every day?
- 04What action has been taken to improve hand sanitising and PPE practice?
- 05Has the action plan requested by the CQC been completed, and what progress has been made before the re-inspection?
This was a focused inspection of Safe and Well-led only; the other question ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 11 March 2021 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, October 2018
Rated Good overall; inspectors found safe, kind and responsive care, but the home's leadership systems still required improvement.
This was an unannounced inspection on 26 September 2018. The inspection team spoke with people living in the home, relatives, staff and managers. They observed care and checked care records, staff files, medicines records, complaints, accidents, audits and other documents.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines administration, suitable care plans, trained staff, good support with food and health needs, kind care, respect for privacy and a range of activities.
Well-led was rated Requires Improvement. Some checks did not identify incomplete medicines records or a care plan that needed updating. The overall rating improved from Requires Improvement at the previous inspection in July 2017, but further work was still needed to make management checks consistently effective.
Enough staff
Inspectors found sufficient staff to meet people's needs, and people said staff responded promptly when they needed help.
“People were supported by sufficient staff. People told us staff responded promptly when they needed assistance.” from the report
Kind and respectful care
People and relatives spoke positively about staff. Inspectors saw staff protecting privacy, maintaining dignity and supporting people in a caring way.
“People were supported by caring staff that protected their privacy and dignity.” from the report
Choices and activities
People were involved in decisions about their care and could take part in activities that matched their interests.
“People could follow their interests and spend time doing activities they enjoyed.” from the report
Improvement since the last inspection
The overall rating improved from Requires Improvement in July 2017 to Good at this inspection. Safe, Effective and Responsive also improved to Good.
“At this inspection we found improvements had been made and the service is rated as Good overall.” from the report
Management checks missed some records
needs fixingAudits did not always identify that an 'as required' medicine record was incomplete. The record did not show the impact of the medicine as required by the home's policy.
“Medicines audits were not consistently completed in line with the policy.” from the report
Care plan was not updated promptly
needs fixingOne person's care plan and risk assessment had not been updated after their needs changed following advice from a health professional. Staff understood the change, and the manager said the documents were updated after the inspection.
“The systems in place to check people's care plans were not always effective in identifying where updates had not been completed.” from the report
One person felt lonely
minorOne person said they could feel lonely and bored and relied on staff for conversation. The manager said they would discuss this with the person and make changes.
“I am in a room full of people but I can get lonely and bored.” from the report
- 01How do you check that 'as required' medicines are recorded fully, including their effect on the person?
- 02How quickly are care plans and risk assessments updated when a person's needs change?
- 03What would you do if my relative felt lonely or bored, and how would you check whether the support helped?
- 04How are families involved in reviewing care plans and decisions about changes in care?
- 05What improvements have been made to the management audit systems since this inspection?
This was an unannounced inspection covering all five CQC questions; end of life care was not reviewed because nobody was receiving it at the time. This explanation was written from the published report of 24 October 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 Copperdown Residential Care Home
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- March 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Copperdown Residential Care Home →
- October 2018Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
Read what inspectors found at Copperdown Residential Care Home →
- September 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- July 2014Inspected but not rated
- October 2013
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 20 January 2011.
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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