CQC report explained · a residential care home
What the CQC found at Maple Leaf Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found improved risk assessments, medicines management, safeguarding and infection control. Staffing levels met people's needs during the visit.
- Effective?
- Good
- Staff had improved induction, training and support. Records showed better capacity assessments and timely applications for legal authorisation where people were deprived of their liberty.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff offered choices, supported independence and involved people and relatives in care planning.
- Responsive?
- Good
- Care plans were described as comprehensive and person-centred. Activities, communication support, complaints handling and end of life planning had improved.
- Well-led?
- Good
- Management oversight, audits, communication and staff morale had improved. Inspectors said more time was needed to ensure the new systems were embedded and sustained.
What inspectors found, February 2022
Maple Leaf Lodge Care Home was rated Good; inspectors found major improvements after an earlier Inadequate rating, with infection control needing continued attention.
This was an unannounced follow-up inspection on 12 January 2022. Inspectors spoke with 19 relatives and 15 staff, observed care, and reviewed care, medicines and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found better risk assessments, medicines systems, staff training, care planning, infection control and management oversight.
The home had previously been rated Inadequate and placed in Special Measures. The provider had made significant improvements and was no longer breaching regulations. The home was no longer in Special Measures.
Inspectors noted that some new systems still needed time to become fully established. They also found that the visiting policy had not matched government guidance at the time, although it was updated after the inspection.
Improved safety systems
Risk assessments and care plans gave staff clearer instructions about keeping people safe. The home had also improved its approach to learning from incidents.
“We found effective oversight and quality assurance processes in place which significantly reduced risk to people.” from the report
Kind and respectful care
Inspectors observed calm, positive interactions. People were offered choices and supported with privacy, dignity and independence.
“Staff were respectful and caring on all interactions we observed.” from the report
Clean environment and infection control
The home was visibly clean, with suitable supplies of protective equipment and systems to monitor infection prevention and control.
“The home was visibly clean in all areas.” from the report
Better leadership and teamwork
Staff and relatives described better communication and support from managers. Audits and action plans were being used to monitor improvements.
“We noted significant improvements in the home's culture and staff morale.” from the report
Visiting policy
needs fixingAt the inspection, the home's visiting policy did not match government guidance. Inspectors found no impact on people, and the provider updated the policy afterwards.
“The provider had developed their own policy in regards of visiting arrangements in the care home, this was not in line with government guidelines.” from the report
Improvements need to last
minorThe new systems were working, but inspectors said they needed more time to become established and continue reliably.
“More time was now needed to ensure the new systems were embedded and sustained into working practices.” from the report
- 01How have you kept the improvements in risk assessments, medicines and incident reviews working since the inspection?
- 02How do you now check that your visiting policy follows current government guidance?
- 03How do you monitor whether the new quality and safety systems are still being followed?
- 04What training and supervision do staff receive for dementia care, falls, behaviour and medicines?
- 05How are residents and relatives involved in reviewing care plans, activities and complaints?
This was an unannounced follow-up inspection after an earlier Inadequate rating, with specific checks on infection prevention and control and COVID-19 requirements, while ratings were given for all five key questions. This explanation was written from the published report of 16 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.
What inspectors found, October 2021
Inspected but not rated; inspectors found serious infection-control and environmental safety problems, with a continued breach of Regulation 12.
This was an unannounced, targeted inspection on 14 September 2021. It focused on infection prevention and control because the home was responding to COVID-19 outbreaks.
Inspectors found that infection risks were not properly identified or controlled. PPE was not always available, clinical waste bins were difficult to reach, and staff did not always check visitors had completed the required testing.
Several areas and items were unclean. Cleaning records were incomplete, equipment had food splatters and stains, and audits had not fixed problems identified at the previous inspection. The service was inspected but not rated, but there was a continued breach of Regulation 12.
Action plan provided
The provider responded to the inspection concerns with an action plan. This gave inspectors some assurance that the provider intended to improve the service.
“The provider responded to the concerns identified with an action plan, which gave us assurance the provider was committed to driving improvement in the service.” from the report
Monitoring systems existed
The home had systems intended to monitor service quality, although inspectors found they were not effective enough.
“The provider had systems in place to monitor the quality of the service.” from the report
More PPE stations
Additional PPE stations had been added since the previous inspection, although inspectors found they were not always adequately stocked.
“Since the last inspection in June 2021 additional PPE stations had been added to the home” from the report
Infection risks not controlled
seriousInspectors found that risks of COVID-19 and other infections had not been properly identified or reduced. Staff greeted inspectors without masks and did not always check visitors had completed the required testing.
“Risk associated with people and staff contracting COVID-19 and the spread of infections had not been adequately identified and risks mitigated.” from the report
Poor cleanliness
seriousSome communal areas, furniture, carpets, kitchenettes and equipment were dirty. Inspectors also saw moving and handling equipment used without cleaning before or after use.
“We found on this inspection only minor improvement. Communal areas in the home, specifically areas that accommodates people with dementia who are unable to ensure their own safety, were unclean.” from the report
PPE and waste access
seriousPPE stations were not always stocked, and there was no allocated role to replenish them. Clinical waste bins were not easy for staff to reach.
“Clinical waste bins were not easily accessible to staff meaning they had to travel through the home with soiled PPE to dispose of it correctly.” from the report
Cleaning checks ineffective
needs fixingCleaning schedules were incomplete or did not identify high-risk areas. Audits and governance systems had not corrected concerns found at the previous inspection.
“IPC audits and governance processes had been ineffective in improving and monitoring the quality of the service.” from the report
- 01What action from the inspection plan has now been completed, and what evidence can you show us?
- 02How do you make sure PPE stations are stocked at all times, and who is responsible for checking them?
- 03How often are communal areas, kitchenettes and moving and handling equipment cleaned and checked?
- 04How do you make sure visitors have completed the required testing before entering the home?
- 05What changes have been made since the previous inspection in June 2021 to prevent the same infection-control problems happening again?
This was an unannounced targeted inspection of infection prevention and control practices during a COVID-19 outbreak; the service was inspected but not rated. This explanation was written from the published report of 21 October 2021 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 Care Home
5 rated inspections over 6 years: the service has held its Good rating throughout.
- February 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2021Inspected but not ratedSafe: Inspected but not rated
- August 2021Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- March 2020Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 30 November 2010.
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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
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