CQC report explained · a residential care home
What the CQC found at Mapleton Road
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from avoidable harm as far as possible. Medicines, staffing, recruitment, infection control and safeguarding were found to be managed safely, although inspectors observed some poor moving and handling practices.
- Effective?
- Good
- Care plans reflected people's physical, mental, communication and functional needs. People received suitable food and drink, staff training and support, healthcare access, and care provided in line with the Mental Capacity Act.
- Caring?
- Good
- The report does not give a separate rating for Caring.
- Responsive?
- Good
- The report does not give a separate rating for Responsive.
- Well-led?
- Good
- Managers were described as visible, approachable and open. Audits, feedback and improvement plans were used to monitor and improve the service.
What inspectors found, August 2023
Rated Good; inspectors found safe, effective and well-led care, but recommended improvements to moving and handling procedures.
Inspectors visited unannounced on 11 and 13 July 2023. They spoke with people, care workers, the manager and relatives. They observed care and checked care records, risk plans, staff files, medicine records and management audits.
The home was rated Good overall, with Good ratings for Safe, Effective and Well-led. Inspectors found enough staff, safe medicine systems, suitable care plans, good support with food and drink, access to healthcare and effective management oversight.
Inspectors did see some poor moving and handling practices. These were addressed immediately, but they recommended that the home review its procedures. Some risk guidance could also be clearer. The previous overall rating was Requires Improvement, published on 9 April 2021.
Enough staff
Inspectors found enough staff to meet people's needs. People were not left waiting and staff did not appear rushed.
“On the day of our visit, we observed that people did not have to wait for support.” from the report
Safe medicines
Medicine records had no gaps, and staff were checked as competent. Medicines were prescribed, given, recorded and stored safely.
“People were supported by staff who followed systems and processes to prescribe, administer, record and store medicines safely.” from the report
Food and healthcare
People were supported to eat and drink enough, with dietary needs recorded and followed. People also had access to healthcare professionals when needed.
“People received support to eat and drink enough to maintain a balanced diet.” from the report
Visible management
Managers were available and approachable. The home used audits, feedback and an improvement plan to monitor the quality of care.
“Governance processes were effective and helped to hold staff to account, keep people safe, protect people's rights and provide good quality care and support.” from the report
Moving and handling
needs fixingInspectors observed some poor moving and handling practices when people were being supported. The issue was addressed immediately, but the provider was asked to review its procedures for all staff.
“We recommend the provider review their moving and handling procedures for all staff.” from the report
Risk guidance
needs fixingSome risk management guidance was not detailed enough for staff. The manager said the assessments would be reviewed and more information added.
“Although we found some guidance for staff to follow, we felt they could be improved in some areas.” from the report
- 01What changes have been made to moving and handling procedures since the inspection?
- 02How do you check that every staff member is competent in moving and handling?
- 03Have all risk assessments been reviewed and given clearer guidance for staff?
- 04How are medicine competencies and records checked over time?
- 05How will you keep families updated if a safety incident happens?
This inspection assessed Safe, Effective and Well-led; Caring and Responsive were not separately rated, and infection prevention and control was included under Safe. This explanation was written from the published report of 15 August 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, April 2021
Requires Improvement; inspectors found improvements in staffing, medicines and safeguarding, but concerns remained about PPE, risk records and quality checks.
This was a focused inspection on 27 January 2021. Inspectors visited the home, spoke with five residents, four relatives and six staff, and reviewed care, medicines, incident and management records.
The home was clean and had many infection control measures in place. Staff understood how to protect people from abuse and manage known risks. Staffing levels and medicines management had improved since the previous inspection.
However, staff were seen wearing PPE incorrectly or not wearing a mask in a communal area. Some risk assessments and care records were not up to date, and records did not always show what the home had learned from incidents.
The overall rating remained Requires Improvement. Safe and Well-led were both rated Requires Improvement. Responsive was inspected but not rated, while Effective and Caring were not covered by this focused inspection.
Improved staffing
Staffing levels had increased and most staff said there were enough staff to meet people's needs without feeling rushed.
“Enough improvement had been made at this inspection and the provider was no longer in breach of regulation 12.” from the report
Medicines
Medicines were stored, administered and recorded properly. The medicines records inspected had no gaps.
“Processes were in place to ensure medicines were appropriately stored, administered and recorded.” from the report
Protection from abuse
Staff knew how to recognise and report abuse, including when to contact outside authorities.
“People were protected from the risk of abuse and systems and process supported this.” from the report
Clean environment
Inspectors found the home clean and saw staff cleaning high-contact areas.
“The environment was clean, tidy and a cleaning schedule was in place for high contact areas” from the report
PPE was not always used safely
seriousInspectors saw one staff member wearing a mask incorrectly and another walking through a communal area without one. This was especially concerning because the home had recently had a COVID-19 outbreak.
“However, we were not always assured staff were using PPE effectively and safely.” from the report
Risk records were out of date
needs fixingOne person's medicines risk assessment had not been reviewed since December 2019 and did not clearly explain the risks or what staff should look for.
“one person's medicine risk assessment had not been reviewed since December 2019 and risks posed were not clearly documented.” from the report
Care records needed updating
needs fixingThe home's checks did not always identify that care records were inaccurate or out of date.
“Regular audits were carried out by the service, however, improvements were required to ensure all care records were accurate and up to date.” from the report
Incident learning was not fully recorded
needs fixingThe home discussed incidents at handovers or team meetings, but records did not always show what action was taken or what had been learned.
“However, evidence of learning and monitoring activity were not always recorded.” from the report
Safeguarding refresher training
needs fixingSome staff had not completed their yearly safeguarding refresher training. Training was planned for 2021.
“Some staff told us, and records showed they had not always completed their yearly safeguarding refresher training.” from the report
- 01What checks are now used to make sure every staff member wears PPE correctly, particularly during an infection outbreak?
- 02How often are residents' risk assessments reviewed, and how do you make sure they describe the risks and actions clearly?
- 03How do you record what was learned and what action was taken after an accident or incident?
- 04Has the outstanding complaint been resolved, and has the complaints procedure been corrected?
- 05Have all staff completed their yearly safeguarding refresher training?
This was a focused inspection of Safe and Well-led, with specific concerns also checked under Responsive; Effective and Caring were not covered, and some previous ratings carried over. This explanation was written from the published report of 10 April 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 Mapleton Road
4 rated inspections over 7 years: the service has held its Good rating throughout.
- August 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2021Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Inspected but not ratedWell-led: Requires improvement
- August 2019Requires improvementdown from GoodSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- December 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- May 2011
Registered with the Care Quality Commission on 26 May 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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