Copthorne Complete Home Care Limited

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

We identified 3 breaches of the legal regulations. The provider still had not implemented processes to monitor and improve the quality of care and experience. They still had not implemented systems to assess, monitor and mitigate risks relating to the health, safety and wellbeing of people. As a result, people did not always have good quality or safe care delivered to them. The most recent inspection rating was not displayed at the provider’s premises. Conditions on the provider’s registration had not been followed.

This service scored 25 (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.

The registered manager could not demonstrate they had the skills and competency to lead effectively at all times. They could not tell us how they had kept themselves up to date with learning in adult social care to ensure people received a good standard of care. They did not fully understand their responsibilities, for example to notify the local authority and CQC of safeguarding incidents, the management of risk or for completing quality assurance checks.

There were no processes in place where the registered manager could be proactive and develop a positive culture of safety within the service. They did not demonstrate openness in which concerns about safety were listened to because there was no identifiable action taken when injuries were raised with them. The registered manager did not investigate safety events and they did not have a process in place to identify lessons were learnt. They had not displayed integrity and had not kept information and discussions with people private.

Staff did not have information on how to raise concerns or have an understanding about how to whistleblow. Whistleblowing is the action someone takes to report wrongdoing at work that affects others. Staff did not understand who to contact outside of the providers organisation if they needed to speak up. Staff felt the manager was supportive and felt they could talk with them if they needed. However, if they had concerns about the registered manager staff did not know who they could contact to share these concerns.

The registered manager did not foster a positive culture where people felt they could speak up or that their voice would be heard. Information was not provided in a way which was accessible to people, which excluded them from decisions about their care and support. Capacity assessments on people were not completed, and relatives made some decisions without evidence they had the legal authority to do so. People were not engaged in a way which supported their feedback on the care they received. The provider did not have a process in place for receiving comments on care and had not identified a means for acting on feedback.

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 registered manager did not understand their responsibilities in relation to their registration with us. They did not have any quality assurance systems in place. They also did not complete any checks or reviews on people’s care records, risk assessments, people’s capacity or the administration of medicine.

The provider had not implemented clear responsibilities, roles, systems of accountability and good governance. The provider's oversight of staff knowledge and competencies was insufficient to ensure staff were skilled and trained to carry out their roles. The provider had no quality systems in place to assess, monitor and mitigate risks relating to the health, safety and welfare of people. The provider had failed to display their most recent inspection rating, which is a requirement of their registration with us. The registered manager was not aware they had to do this. The provider had failed to comply with some of the conditions on their registration which we had issued after their last inspection. This put people at the risk of receiving care which was potentially unsafe, did not meet their needs and was delivered by staff whose skills could not be assured.

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.

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