CQC report explained · a residential care home
What the CQC found at Coppice Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2019
Rated Requires Improvement; inspectors found kind, person-centred care, but medicines and management systems needed more work.
Inspectors visited the home without warning on 11 and 12 September 2019. They spoke with people, staff and managers, observed care, and checked care plans, medicines records, complaints and quality checks.
There had been clear improvement since the previous inspection, when the home was rated Inadequate and placed in special measures. People were supported with dignity, choice and independence. Inspectors rated Effective, Caring and Responsive as Good.
The home was still rated Requires Improvement for Safe and Well-led. Some prescribed creams were not given as recorded, staff did not always raise safety concerns promptly, and new management and checking systems had not yet been fully established.
The home was no longer in special measures and was no longer breaching regulations at this inspection. CQC said it would continue to monitor the home until the improvements were properly embedded.
Respect and independence
People were involved in everyday decisions and supported to gain skills and take part in running the home.
“Staff gave us examples of the care provided which helped people to increase their independence and to be involved in the running of the home.” from the report
Activities and community life
People had more opportunities to go out, attend clubs, enjoy meals out and take part in activities at home.
“People now enjoyed spending more time in the community, attending clubs and enjoying meals out and gentle exercise, as they chose.” from the report
Staffing
Inspectors found enough staff to meet people's needs. Shift patterns were adjusted to support people's choices, and a consistent group of agency staff was used when needed.
“There was enough staff to care for people.” from the report
Creams were not always given correctly
needs fixingSome people did not receive prescribed creams as recorded. Inspectors said this could increase the risk of poor skin health, and further checks were planned.
“There were some instances when people did not receive creams as prescribed.” from the report
Safety concerns were not always escalated
needs fixingAn outside support worker raised a night-time safety concern that had not been reported to the manager. The provider needed more time to establish a culture where staff raised concerns immediately.
“The provider needs more time to embed and establish a culture where staff immediately escalate concerns.” from the report
Management was not yet stable
needs fixingThere was no registered manager at the time of the inspection, and the home had had three managers since the previous inspection. New management and quality systems still needed to become consistent.
“There was no registered manager in post at the time of the inspection.” from the report
- 01How do you now check that prescribed creams are given and recorded correctly every time?
- 02What should staff do if they notice a safety concern, and how do you check that concerns are escalated promptly?
- 03Is there now a registered manager for the home, and how long have they been in post?
- 04Which new quality and safety checks are now complete, and what action is taken when they find a problem?
- 05What improvements have been made to the garden, furniture, maintenance and planned sensory room since this inspection?
This was an unannounced planned follow-up inspection that looked at the whole care home, including the premises and care provided; all five key questions were rated. This explanation was written from the published report of 20 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, May 2019
Coppice Lodge was rated Inadequate and placed in special measures; inspectors found some safer choking support but important risks and management weaknesses remained.
This was an unannounced focused inspection on 10 April 2019. Two inspectors looked mainly at how the home managed choking risks for people with swallowing difficulties. They sampled four people's care and medicine records, observed a lunchtime meal, and spoke with staff and managers.
Staff understood people's swallowing needs and generally prepared and served food safely. Care plans gave useful guidance, and medicines were provided in suitable liquid forms where needed. However, daily records did not always describe food and drinks accurately enough to show that guidance had been followed.
The home had new management and was developing quality checks. Inspectors saw some signs of improvement, but these changes were not yet firmly established. The overall rating stayed Inadequate, as did the ratings for Safe and Well-led, based on this inspection and the previous comprehensive inspection.
Staff followed swallowing guidance
During the observed meal, staff supported people in line with their care plans and adjusted food, drinks and assistance to their individual needs.
“The assistance provided by staff during their lunchtime meal reflected the guidelines in people's care documentation so risks to people from choking was mitigated.” from the report
Care plans gave detailed guidance
People's risk assessments and care plans described their swallowing needs and how food should be prepared.
“Risk documentation also gave guidance for staff to follow in the preparation and management of people's eating and drinking needs.” from the report
Some medicines met swallowing needs
Liquid medicines were available for people who needed them. Staff had also discussed one person's crushed tablets with health professionals, although the legal decision-making process was incomplete.
“Where people required their medicine in liquid forms this was made available to them, so their needs and safety was maintained.” from the report
New management was starting improvements
A new manager was working with senior managers to improve staff practice and introduce more quality checks.
“Since our last comprehensive inspection, a new manager has been appointed and they were working with the provider's senior management team to drive through improvements.” from the report
Meal records were incomplete
seriousDaily notes did not always record the full description of meals and drinks. This meant managers could not always confirm that food and drinks had been prepared safely.
“Although the staff we spoke with understood people's individual swallowing needs the daily records were not always completed to accurately describe the meals provided.” from the report
One drink was not fully recorded
needs fixingA person's drinks needed to be prepared in a particular way, but the daily notes did not record that preparation method.
“Although, staff were able to tell us about this person's needs the daily notes where staff documented how much the person drank did not include the specific way these were prepared.” from the report
Medicine decision-making was incomplete
seriousOne person's tablets were crushed into food to help with swallowing. Although this had been discussed with health professionals, the decision had not been recorded using the Mental Capacity Act principles.
“However, this specific decision this was not followed through using the principles of the Mental Capacity Act.” from the report
Quality systems were not yet established
needs fixingThe home had introduced checks, but inspectors said they needed more time to show that improved practice would continue.
“However, more time was required to ensure the improvements in staff practices in relation to managing people's choking risks were embedded and sustained in the longer term.” from the report
- 01How do you now record the exact texture and preparation of each person's food and drinks?
- 02What checks are made each day to confirm that staff have followed every person's swallowing guidance?
- 03Is there now a registered manager, and what has changed since the inspection?
- 04How are decisions about crushing medicines recorded and reviewed under the Mental Capacity Act?
- 05What action has been taken in response to the home's special measures status and the restriction on admissions?
This was an unannounced focused inspection of Safe and Well-led issues linked to swallowing and choking risks; the other key question ratings were not assessed and the overall rating carried over from the previous comprehensive inspection. This explanation was written from the published report of 22 May 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.
Every inspection of Coppice Lodge
3 rated inspections over a year: the service has improved, from Inadequate to Requires improvement.
- November 2019Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2019Inadequatestayed InadequateSafe: InadequateWell-led: Inadequate
- March 2019InadequateSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- February 2018
Registered with the Care Quality Commission on 1 February 2018.
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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