About the service: Coppice Lodge is a residential home registered to provide accommodation with personal care for up to eight people with a learning disability. There were six people living at the home at the time of our inspection visit.

The service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with a learning disabilities and autism using the service can live as ordinary a life as any citizen.

People’s experience of using this service:

¿ Staff had not always detailed the full description of the food and drinks provided to safely meet people’s needs.

¿ The management team were continuing to develop their quality checks, so they could be assured people with specific eating and drinking needs had these met effectively and safely.

¿ People were supported by staff who understood how to prepare and serve people their food and drinks so people could safely and comfortably enjoy these.

¿ People’s care and risk plans guided staff in providing safe and consistent support to people when eating and, external professionals had been consulted.

¿ People received their medicine in a way which met their individual swallowing needs.

¿ The management of the home had changed since the last comprehensive inspection. The manager showed commitment and enthusiasm to implement the changes needed to improve staff practices so risks to people from choking were consistently managed and mitigated.

Rating at last inspection: At the last comprehensive inspection undertaken on 16 January 2019 the rating was Inadequate and the report was published on 5 March 2019. At this inspection the rating has not changed because our focus was on people who required care and support from staff to meet their swallowing needs and, mitigate the risks of choking.

Why we inspected: We undertook this focused inspection because we had received information of concern in relation to people who required staff to support them in reducing the risks of choking. As a result, the team inspected the service against two of the five questions we ask about services: is the service safe and is the service well led, specifically linked to people with swallowing needs. This report only covers our findings in relation to this and therefore, the ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Coppice Lodge on our website at www.cqc.org.uk.

Enforcement: At the previous comprehensive inspection we identified five breaches of regulation of the Health and Social Care Act (Regulated Activities) Regulations 2014. We issued an urgent Notice of Decision to impose conditions on registration and restriction on admissions into the home. We found the service was inadequate overall, and in the key questions safe, effective and well-led. The inspection identified five breaches of regulation of the Health and Social Care Act (Regulated Activities) Regulations 2014. The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not, enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to v

The provider registered with the Care Quality Commission (CQC) in February 2018. This was the first inspection under this provider and therefore their first rating.

Coppice Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Coppice Lodge accommodates eight people with a learning disability in one adapted building which is over two floors. There were seven people living in the home when we completed our inspection visit.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. Registering the Right Support CQC policy

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager, while still active on the register, left the company in April 2018. The manager who we met on inspection had worked in the home for three weeks prior to our arrival.

At this inspection we found the service was inadequate overall, and in the key questions safe, effective and well-led. The inspection identified five breaches of regulation of the Health and Social Care Act (Regulated Activities) Regulations 2014. The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Where risks to people's health were identified people had not been adequately assessed or reviewed to understand if the support in place was adequate. Staff were not provided with clear and accurate guidance as care records were not readily available, incomplete and historic to ensure people risks of harm were being managed and mitigated in the right way. This exposed people to potential harm of unsafe care and treatment. There were sufficient staff to keep people safe. People's as required medication was not always managed in a safe way; as staff did not have clear guida