Copper Beeches

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to, people’s safe care and treatment, health and safety, risk management and staffing.

This service scored 59 (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 did not always have a proactive learning culture of safety. Lessons were not always learnt to identify and follow good practice. We found staff did not always record enough information to allow information to be reviewed and lessons could be learnt. We found there was not a culture of an effective review of accidents and incidents to identify patterns, trends, or lessons learnt on how to mitigate future risks. This meant people were placed at continued risk of incidents reoccurring. Records showed the provider had not ensured the duty of candour was always followed.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The management team had not always followed their safeguarding policy, training, and best practice guidance on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect. There was not an effective management oversight of incidents, accidents and safeguarding concerns which meant they were not reported and investigated in an appropriate way to reduce risk of reoccurrence. This placed people at continued risk of harm. For example, systems and processes were not in place to safeguard people from abuse. We found incidents of harm and injury that had not always been reported to the local authority safeguarding team. We found where people had a fall, and an injury had been sustained they were not reported this meant people were at continued risk of harm. People told us they felt safe, and staff treated them well.

The provider did not always work with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe. People told us they had not been provided with the opportunity to be part of their care planning or risk management plans. This meant people were not involved in managing their own risks. We found people did not always have detailed and personalised risk assessments or management plans to guide staff about risks on their health and welfare and how to minimise those risks. For example, a person had been diagnosed with diabetes and there was no care plan in place for staff to follow. This placed the person at an increased risk of further health conditions developing and risk of harm if appropriate timely diabetic care was not provided. Furthermore, there were no clear plans of care and best practice approaches to support people and manage risk in relation weight loss. Monitoring systems were not effective, staff had recorded peoples weight loss but failed to take action or obtain health advice. People’s food and fluid intake was not always recorded for effective monitoring to ensure they were eating and drinking properly. This meant people were at risk of harm.

The provider did not always detect and control potential risks in the care environment. The environment was not managed to ensure it was safe. The fire risk assessment was due to be reviewed November 2024 in line with good practice guidance. We found the fire risk assessment showed there were 33 actions to be completed and there was no evidence to demonstrate these actions had been completed. This placed people at continued risk of harm in an event of a fire. Since our visit the provider had a fire risk assessment completed on 29 January 2025 that evidenced 13 actions to be complated. We asked the provider for an action plan. We found all the top floor bedroom doors that were fire doors did not close properly and left a significant gap. This poses a significant risk to residents and staff in the event of a fire. Furthermore, we found people were at risk of scalding. We found two radiators at the home uncovered and hot to touch. Copper Beeches supported several people with dementia who would be at risk of harm and would not call for help. We observed people during lunch time were supported to sit next to one of the uncovered radiators and one of the people continued to touch the hot radiator. This placed people at increased risk of harm.

The provider did not always make sure there were enough qualified, skilled, and experienced staff. We found there was inadequate staffing levels during the night and people were at risk of neglect and harm. There were 2 staff on shift, however, up to 4 people required care and support from 2 staff. This meant there would be long periods of time where people would be left unsupervised and at risk of harm. Staff had not completed adequate training; training records showed gaps where staff had not completed all their training to ensure they had the right skills to do their role. For example, Staff had not received appropriate falls training and were not competent supporting people who had fallen and had a head injury. We found 5 incidents where a head injury had occurred, and staff failed to obtain health advice on 4 occasions. This placed people at the risk of harm. Staff had received support, supervision from the management team. We revived mixed feedback from relatives. The comments were, “Sometimes probably not, but most times they do have enough staff.” “When I go there, I see a number of staff but when I speak to them, they say they are busy. When I ring, I usually can’t speak to someone straight away.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. We found the home was clean and odour free. The service had dedicated housekeeping staff who ensured the service was clean and infection control was managed well. Relatives told us the home was always clean and well maintained. On relative told us, “It is outstandingly clean.” Another relative told us, “It is very clean – perfect.”

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.