Copper Beeches

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance at the service.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Not all leaders understood the context in which the provider delivered care, treatment, and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience, and credibility to lead effectively. For example, the management team were not always aware of their responsibility to ensure the building was safe and people were not at risk of harm. The management team had not ensured staff were trained or provided with the skills needed. Care plans did not provide staff with clear information to ensure people were provided with safe care and treatment or they did not always do so with integrity, openness, and honesty.

People felt they could speak up and that their voice would be heard. People told us the manager and provider were approachable and would listen. People were not afraid of speaking up and felt they would raise concerns if needed. A relative told us, “I have talked to them [staff] about things which concern me, and I was listened to.” Another relative told us, “They [staff] are very approachable and nice.”

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. We found management systems and processes had not identified the shortfalls in governance. Management audits failed to identify the concerns and risks we found at the service. For example, in identifying the health and safety risks of the building. The service had not recorded incidents and accidents well and had insufficient staffing levels to keep people safe. Care records did not provide enough guidance to staff. The registered manager did take immediate action to some of the concerns we identified during the visit such as ensuring fire doors were not wedged open and areas of the home were locked that could pose a risk to vulnerable adults.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome, and quality of life for people. They did not always actively contribute to safe, effective practice and research. The staff team were not able to demonstrate what learning had taken place from past visits from when other professionals highlighted concerns. During our visit we found similar concerns that had been highlighted to the provider in 2024 regarding fire safety. We found no system and processes to learn from incidents and accidents to make the necessary improvements this meant people were at continued risk of harm.