CQC report explained · a nursing home
What the CQC found at Maple Lodge Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that people were protected from avoidable harm. Medicines, risk assessments, fire safety, infection control, staffing, recruitment and safeguarding arrangements were generally managed safely, although some parts of the environment needed improvement.
- Effective?
- Good
- This key question was not inspected at this visit, so no new rating was given in this report.
- Caring?
- Good
- This key question was not inspected at this visit, so no new rating was given in this report.
- Responsive?
- Good
- This key question was not inspected at this visit, so no new rating was given in this report.
- Well-led?
- Good
- Inspectors found that the home was consistently managed and had a positive, person-centred culture. Audits, action plans, staff meetings and feedback systems supported improvement.
What inspectors found, January 2023
Rated Good; inspectors found safe, kind and well-managed care, but some areas of the home were unclean and needed refurbishment.
This was an unannounced inspection on 14 December 2022. One inspector and an Expert by Experience spoke with people, relatives, staff and visiting health professionals. They also checked care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. People and relatives said they felt safe and were happy with their care. Medicines, risk assessments, fire checks, infection control, staffing and safeguarding systems were found to be managed safely.
Inspectors found that some parts of the building looked tired and unclean. Bathroom and hallway flooring needed replacing. Some improvements had started and more were planned, so the CQC made a recommendation for further environmental improvement.
The home had previously been rated Requires Improvement, with breaches of regulations. Inspectors found enough improvement had been made and the home was no longer in breach. Only Safe and Well-led were inspected at this visit, and the other ratings carried over from the previous inspection.
Medicines managed safely
People received their medicines as prescribed and at the right time. Records were completed accurately, including instructions for medicines taken only when needed.
“People received their medicines as prescribed and at the right time. Medicine records were accurately completed.” from the report
Enough suitable staff
Inspectors found there were enough staff to meet people's needs and keep them safe. Recruitment checks were also described as robust.
“There were enough staff to meet people's individual needs and maintain their safety.” from the report
People felt safe
People and relatives told inspectors they felt safe. Staff knew people well and understood how to protect them from abuse.
“People's relatives told us they felt their family members were safe.” from the report
Positive management
The home had a relaxed and welcoming atmosphere. Staff felt respected, supported and able to raise concerns or ideas.
“Management and staff put people's needs and wishes at the heart of everything they did.” from the report
Tired and unclean areas
needs fixingSome areas required refurbishment and were not clean. Inspectors said bathroom and hallway flooring needed replacing, and recommended that this was added to the improvement plans.
“Some areas of the home looked unclean and needed refurbishment.” from the report
Further environmental work needed
needs fixingAlthough some improvements had been made, inspectors were only somewhat assured that the premises supported safety because refurbishment was still needed.
“We were somewhat assured that the provider was promoting safety through the layout and hygiene practices of the premises due to refurbishment needs.” from the report
- 01Which areas were unclean or tired when inspectors visited, and what work has been completed since then?
- 02When will the bathroom and hallway flooring be replaced?
- 03How will you monitor the improvement plan and provide assurance that the environmental work is completed?
- 04How many agency staff are currently being used, and how are you reducing reliance on agency staff?
- 05How can residents and relatives raise concerns about the environment or the care provided?
This was a planned inspection based on the previous rating and focused on Safe and Well-led, with infection prevention and control also checked; the other ratings carried over from the previous inspection. This explanation was written from the published report of 10 January 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, December 2021
Maple Lodge Care Home was rated Requires Improvement; inspectors found unsafe medicines management, risks not always followed and weak oversight.
This was an unannounced inspection on 14 October 2021. An inspector, a pharmacist inspector and an expert by experience visited, spoke with people and managers, reviewed records and audits, and later spoke by telephone with staff and relatives.
The home was not always safe. Some medicines were unavailable, records and instructions were incomplete, and fridge temperature records raised concerns about storage. Staff did not always follow risk assessments for people at risk of falls. There were also some problems with PPE use and staff deployment at busy times.
The home had enough staff overall, recruited staff safely and had fire safety and safeguarding arrangements. People and relatives gave positive feedback, and staff described a supportive team culture. However, management checks did not identify all the problems found by inspectors.
The overall rating fell from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The provider was told to send an action plan, and CQC said it would monitor progress and inspect again.
Safeguarding
Staff had safeguarding training and knew how to raise concerns. The report says investigations and appropriate action were taken when concerns were raised.
“People were safeguarded from the risk of abuse.” from the report
Positive staff culture
People and staff gave positive feedback about the manager and the atmosphere in the home. Staff said they could raise ideas or concerns.
“Staff responses about the culture of the home were positive regarding the manager and staff morale.” from the report
Fire and building safety
The home had personal emergency evacuation plans, fire safety procedures, equipment checks and regular maintenance checks.
“Fire safety procedures were in place along with regular checks of equipment.” from the report
Infection control arrangements
Inspectors were assured about several infection control arrangements, including testing, admissions and managing outbreaks. They were only somewhat assured about the safe use of PPE and some premises practices.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Medicines
seriousSome medicines were not in stock, so they could not be given as prescribed. Instructions and records for some medicines were missing or incomplete, and fridge temperature records did not show that medicines were stored safely.
“The provider failed to ensure people received their medicines safely.” from the report
Risks were not always followed
seriousInspectors saw people at risk of falls whose risk assessments and care plans were not being followed. This was identified as a breach of Regulation 12.
“We observed people who were at risk of falls during our inspection where their risk assessments and care plans were not being followed.” from the report
Weak management checks
seriousAudits did not identify all the problems found with medicines and risk assessments. This was identified as a breach of Regulation 17 on good governance.
“The provider's systems to audit the quality and safety within the service were not always effective.” from the report
Staff cover and records
needs fixingThere were enough staff overall, but some areas had minimal cover at busy times. Several documents were missing from staff files, and inspectors recommended changes to deployment and record checking.
“However, we observed areas of the home with minimal staff cover.” from the report
PPE use
needs fixingSome misuse of PPE was observed. The manager addressed this during and after the inspection.
“Some misuse of PPE was observed during our inspection.” from the report
- 01What has changed to ensure every prescribed medicine is in stock and given safely?
- 02How are fridge temperatures for medicines recorded and checked now?
- 03How do managers check that staff follow falls risk assessments and care plans in practice?
- 04What changes have been made to staff deployment at busy times?
- 05What evidence can you show that audits now identify and correct medicines, risk assessment and staff record problems?
This was a focused inspection prompted by concerns about medicines and infection control, and it rated Safe and Well-led; Effective, Caring and Responsive were not rated in this report. This explanation was written from the published report of 10 December 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 Lodge Care Home
5 rated inspections over 5 years: the service has held its Good rating throughout.
- January 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- February 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- August 2017GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2016
Registered with the Care Quality Commission on 23 May 2016.
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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