CQC report explained · a residential care home
What the CQC found at Maple Leaf Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found kind, personalised care, but medicines, records and management checks were not always reliable.
This was an unannounced inspection on 26 September 2023. The inspector and an Expert by Experience reviewed care plans, medicines, staff recruitment and management records. They also spoke with people, staff and relatives.
People were treated with kindness and respect. Staff supported independence, choice, communication, activities and access to health professionals. Inspectors rated Effective, Caring and Responsive as Good.
There were important safety and management problems. One person's medicines were not always given as prescribed, some health and safety records had gaps, and some care information needed updating. Safe and Well-led were rated Requires Improvement. The overall rating changed from Good at the previous inspection to Requires Improvement.
Kind and respectful care
Inspectors saw staff providing compassionate care and using language people understood. People's privacy, dignity and equality were respected.
“We observed that people received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to.” from the report
Choice and independence
Staff focused on people's strengths and supported them to make choices about their care, rooms, activities and everyday lives.
“Staff focused on people's strengths and promoted what they could do, so people had a fulfilling and meaningful everyday life.” from the report
Personalised support
Care plans reflected people's needs, communication preferences, health and longer-term goals. Staff adapted support as people's needs changed.
“People had care and support plans that were personalised, holistic, strengths-based and reflected their needs and aspirations, including physical and mental health needs.” from the report
Activities and community access
People were supported to take part in activities they chose, including outings, social interests and religious activities.
“We saw that activities offered included trips out, going to the cinema, an escape room, a theme park and going bowling.” from the report
Medicines were not always given as prescribed
seriousOne person's medicines were not always administered as prescribed. There were no records showing what action had been taken when the person refused medicines.
“We found that one person's medicines were not always administered as prescribed.” from the report
Important care and safety records
needs fixingA health passport did not contain important information that could potentially put other people at risk. Some health and safety checks were also missing when inspectors arrived.
“We found some gaps in health and safety records.” from the report
Management checks were not reliable enough
needs fixingThe home's governance systems did not always identify or prevent problems with records and medicines. There was also no registered manager in post at the inspection.
“Governance processes were not always effective.” from the report
Communication with relatives
needs fixingSome relatives said communication with the home needed improvement, including delays in receiving replies and not being told about a diagnosis.
“Some people's relatives told us that communication with the service required improvement.” from the report
- 01What has changed in the system for recording and checking medicine administration since the inspection?
- 02How do you make sure health passports and risk assessments contain all information needed to keep people safe?
- 03How often are health and safety checks completed, and how are missed checks followed up?
- 04How will you keep relatives informed about changes in a person's health and respond to calls promptly?
- 05Has the manager now registered with the CQC, and who is responsible for checking the home's improvement plan?
This was an unannounced inspection covering all five CQC questions, including the home, care, medicines, staffing and management records. This explanation was written from the published report of 23 November 2023 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, February 2022
Maple Leaf Lodge was inspected but not rated; inspectors found well-managed COVID-19 infection control and visiting arrangements.
This was a targeted, announced inspection on 26 January 2022. Inspectors looked at infection prevention and control, visiting arrangements and whether staffing pressures linked to COVID-19 were affecting the home.
Inspectors found that government guidance was being followed. Records of vaccinations, isolation periods and COVID-19 test results were organised. Cleaning schedules were completed, and plans were in place for outbreaks, cross-contamination and people who could not safely distance or self-isolate.
The home was inspected but not rated. This report does not give a full rating of the quality of care across all five areas.
Organised COVID-19 records
The home kept organised records covering vaccinations, isolation periods and test results.
“The manager had good oversight and an organised approach to recording people's vaccination status, isolation periods and COVID-19 test results.” from the report
Infection control
Inspectors found that infection risks were managed well, including when people could not socially distance or self-isolate.
“Maple Leaf Lodge managed risk in relation to infection well.” from the report
Cleaning and outbreak planning
Cleaning schedules were completed, and the home had plans to manage outbreaks and reduce cross-contamination.
“Cleaning schedules were completed and comprehensive.” from the report
Visiting arrangements
Inspectors were assured that visits were being supported in line with the guidance in force at the time.
“We were assured the provider was facilitating visits for people living in the home in accordance with the current guidance.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you managing any current staffing pressures, and what effect could these have on people's support?
- 02How do you record and check residents' COVID-19 vaccination status, isolation periods and test results?
- 03What happens if someone cannot socially distance or self-isolate?
- 04How will visits be managed if there is a suspected or confirmed outbreak?
- 05How often are cleaning schedules and infection control arrangements checked?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures, so the service was inspected but not rated overall. This explanation was written from the published report of 12 February 2022 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 Maple Leaf Lodge
4 rated inspections over 9 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2014GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 13 January 2011.
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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Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
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