CQC report explained · a nursing home
What the CQC found at Coppice Lea
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2019
Coppice Lea was rated Good; inspectors found safe, kind and responsive care, with some records and activities needing improvement.
This was an unannounced inspection on 23 October 2019. Inspectors spoke with people living in the home, relatives, staff and health professionals. They observed care and checked care plans, medicines, staff files and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People generally said staff were kind, they felt safe, received the care they needed and enjoyed the activities. The home was clean, medicines were managed safely and people received food, drinks and health care.
Inspectors still found some shortfalls. People staying in their rooms might not always receive enough social contact. Some care records were incomplete or contradictory. One bathroom was unusable because it was full of wheelchairs, and one person was not initially receiving their recommended diet. The report says the diet issue and some paperwork problems were dealt with during or shortly after the inspection.
Kind and respectful care
People described staff as kind and caring. Inspectors saw staff supporting people patiently and respectfully, including when someone needed encouragement to eat.
“People told us staff treated them with kindness and we observed kind and caring interactions between people and staff.” from the report
Safety and risk management
Staff knew how to report concerns and followed guidance about falls, choking, pressure sores and fire safety. Personal evacuation plans were in place.
“Risks to people had been identified and action taken to help keep people safe.” from the report
Medicines were managed safely
Medication records were complete when checked, and medicines were stored securely. As-needed medicine instructions had improved since the previous inspection.
“We reviewed several MARs and found no gaps which told us people had been given their medicines correctly.” from the report
Health care and nutrition
People could see health professionals when needed. Staff monitored food and drink intake for people at risk and followed specialist diet guidance in most cases.
“People had access to healthcare input when they required it.” from the report
Complaints were followed up
The home had recorded, investigated and responded to complaints. Inspectors found no open or outstanding complaints.
“15 complaints had been received this year.” from the report
Social contact for people in rooms
needs fixingPeople who did not or could not use communal areas might not receive enough individual stimulation. Inspectors recommended improving this.
“We recommend the registered provider ensures people who are not able or do not wish to sit in communal areas are provided with enough stimulation.” from the report
Care records were not always consistent
needs fixingSome records were incomplete or contradicted other records. Examples included different repositioning instructions and a missing alarm pendant.
“Although people's care plans were reviewed monthly, we found some records were incomplete or contradictory.” from the report
Bathroom access
needs fixingOne bathroom was unusable because it was being used to store wheelchairs. Inspectors were told it was being refurbished and said they would check this later.
“However, we found one bathroom full of wheelchairs and as a result unusable.” from the report
First aid box checks
minorSome items in one first aid box were out of date. The issue was reported to the manager and addressed during the inspection.
“We did identify some out of date items in one of the first aid boxes at the service and alerted the registered manager to this who addressed this.” from the report
- 01How do you make sure people who stay in their rooms receive regular one-to-one company and activities?
- 02How are care records checked so that instructions, such as repositioning times and equipment needs, are complete and consistent?
- 03Has the bathroom that was full of wheelchairs been refurbished and made available for people who want a bath?
- 04How do you check that each person receives the diet recommended by health professionals?
- 05How do you check first aid boxes and other safety equipment for expired items?
This was a planned, unannounced inspection covering all five CQC questions; the report says the home had improved from Requires Improvement at the previous inspection and was no longer in breach of regulations. This explanation was written from the published report of 15 November 2019 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
Coppice Lea was rated Requires Improvement; inspectors found unsafe gaps in risk management, staffing and care records, with nine breaches identified.
The inspection was unannounced and took place on 15 August 2018. Inspectors spoke with people, relatives, staff and healthcare professionals. They observed care and checked care plans, medicine records, recruitment files and quality checks.
The home was not consistently safe or well organised. Inspectors found that risks were not always managed, staffing and staff deployment were sometimes inadequate, and care plans often contained missing or outdated information. Staff did not always follow guidance about eating, drinking, moving people or preventing pressure sores.
People had mixed experiences. Some people spoke positively about staff, food, activities and end-of-life care. Others experienced delays, loneliness, limited contact with staff and a lack of privacy. The provider had started making changes, including extra management support, but these improvements were not yet fully established.
All five areas were rated Requires Improvement. This means the home was not consistently meeting the expected standard at the time of the inspection. The previous inspection in August 2016 had rated the home Good.
Routine medicines
People generally received their prescribed medicines on time. Storage, medicine records and specialist equipment were checked and managed safely.
“People received their medicines when they needed them.” from the report
Safe recruitment
The home carried out appropriate checks on new staff, including checks to help ensure unsuitable people were not employed.
“Appropriate checks were carried out to help ensure only suitable staff were employed to work at the home.” from the report
Activities
People who could access communal areas enjoyed a range of clubs, outings and other activities during the week.
“There were also a 'Gentleman's Club' and 'Ladies Club' which ran on alternate week.” from the report
End-of-life care
People approaching the end of their lives received care that reflected their needs and preferences. Relatives said staff were supportive, and end-of-life plans were detailed and current.
“People were supported at the end of their life to have, as far as possible a dignified and pain free death.” from the report
Risks were not always controlled
seriousInspectors found unsafe practice involving choking, pressure sores, air mattresses and fluid monitoring. Staff did not always follow people's written instructions.
“The identified hazard of choking had not been managed to ensure the person was not put at risk of harm.” from the report
Staffing delays
seriousMinimum staffing levels had not been met on 12 occasions in the previous three weeks. One person waited 10 minutes for a response to their call bell.
“In total the person had waited 10 minutes for a member of staff to attend to them.” from the report
Poor care records
needs fixingCare plans contained outdated, missing or conflicting information. This created a risk that permanent and agency staff would not know people's current needs and preferences.
“Care plans were large files with conflicting or out of date information.” from the report
Privacy and dignity
needs fixingStaff were seen entering rooms without knocking and sometimes spoke to people in an instructive rather than respectful way. People who stayed in their rooms had less interaction and activity.
“This meant people had no privacy in their rooms as staff entered without warning.” from the report
Consent and legal rights
seriousMental capacity assessments, best-interest decisions and records of who had legal authority to make decisions were inconsistent. Some DoLS authorisations had not been removed when they were no longer needed.
“This meant people lacking capacity were at risk of being restricted of their liberties unlawfully.” from the report
Complaints not always resolved
needs fixingManagement had proposed actions to address complaints, but staff did not always carry them out. The report says complaint handling had improved in July and August 2018.
“The provider had not taken effective action to ensure complaints had been resolved.” from the report
- 01What has changed since the inspection to make sure staffing levels and staff deployment are safe on every shift?
- 02How do you now check that staff follow swallowing, moving, pressure sore and hydration instructions?
- 03How are care plans kept up to date, especially when agency staff are working?
- 04How do you check that people's consent, mental capacity assessments, best-interest decisions and DoLS records are correct?
- 05How are complaints recorded, followed up and checked to make sure agreed actions are completed?
This was an unannounced inspection prompted by concerns and it examined all five key questions, including care, staffing, risk management, complaints and leadership. This explanation was written from the published report of 31 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. The report was longer than we could read in one go; the later sections may not be reflected.
Every inspection of Coppice Lea
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- November 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- August 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- March 2014
Report published without a new overall rating.
- July 2013
Registered with the Care Quality Commission on 4 July 2013.
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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