CQC report explained · a residential care home
What the CQC found at Mapperley Lodge
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People had individual risk assessments, suitable staffing and safe medicines systems. Inspectors identified a fire safety risk because two people smoked in their bedrooms, and the provider sought advice from the fire and rescue service after the inspection.
- Effective?
- Good
- Care plans were regularly reviewed and people were supported with choices, food, independence and healthcare. Staff had completed the training the provider considered necessary.
- Caring?
- Good
- This key question was not inspected separately in this visit, so no separate rating is given in this report.
- Responsive?
- Good
- This key question was not inspected separately in this visit, so no separate rating is given in this report.
- Well-led?
- Good
- Inspectors found clear management arrangements, regular audits and an open culture. People, relatives and staff were involved in giving views about the service.
What inspectors found, January 2024
Mapperley Lodge is rated Good; inspectors found safe, kind and well-managed care, with fire safety around bedroom smoking needing attention.
The unannounced inspection took place on 15 November 2023, with follow-up calls to relatives until 22 November. One inspector and one Expert by Experience visited. They spoke with five people, five staff members and two relatives, and checked care, medicines, recruitment and management records.
The home supported six people and could support up to seven. Inspectors rated Safe, Effective and Well-led as Good. They found individual care plans, suitable staffing, safe medicines management, trained staff and prompt access to health services. People were supported to make choices, stay independent and keep in touch with family and friends.
Two people were smoking in their bedrooms despite this being an identified fire risk. After the inspection, the provider worked with the fire and rescue service for advice on stronger fire safety risk management. The overall rating remained Good. The previous provider was also rated Good in January 2018, but the home now has a new provider.
Choice and independence
Staff supported people to make everyday choices and do as much as possible for themselves. Their communication needs and personal preferences were included in care planning.
“Staff supported people to have the maximum possible choices, control and independence over their own lives.” from the report
Kind, personalised support
People received care from staff who understood their individual needs, communication styles, privacy and dignity. The home had a comfortable, homely atmosphere.
“People received support from kind staff who understood and responded to their individual needs.” from the report
Medicines managed safely
Medicines were stored securely, given at the right times and recorded accurately. Staff had regular training and checks of their competence.
“All the MAR we viewed were up to date and accurately completed.” from the report
Good oversight
The registered manager and operations manager used audits and staff meetings to monitor quality and act when shortfalls were found. Each person also had a named keyworker.
“The registered manager had a range of measures to quality monitor all areas of the service and make continual improvements.” from the report
Fire risk from smoking in bedrooms
seriousTwo people smoked in their bedrooms even though this had been identified as a risk. The provider sought advice from the fire and rescue service after the inspection, so families should ask what has changed and how the risk is now controlled.
“We identified 2 people who had made unwise choices to smoke tobacco products in their personal bedroom spaces despite this being an identified risk.” from the report
- 01What changes have been made to manage the fire risk from smoking in bedrooms?
- 02What advice did the fire and rescue service give after the inspection, and has all of it been acted on?
- 03How will you assess and support my relative's communication needs and preferred ways of making choices?
- 04How will you keep my relative's care plan and health information up to date?
- 05How can families raise concerns, and how will the home show what action was taken?
This was an unannounced inspection of Safe, Effective and Well-led; Caring and Responsive were not separately inspected and the overall rating used the current findings alongside the previous rating. This explanation was written from the published report of 10 January 2024 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, January 2018
Mapperley Lodge was rated Good; inspectors found kind, safe and personalised care, with some records and food-stock improvements needed.
Inspectors carried out a comprehensive, announced inspection on 18 December 2017. They spoke with people living in the home, staff, relatives and health and social care professionals. They also observed care and checked care records, medicines, staffing, training, complaints and quality checks.
The home supported seven people with mental health needs, learning disabilities or autism. Inspectors found people were safe, treated with kindness and supported by staff who understood their needs. People had choices, were encouraged to be independent and were supported to take part in activities and community life.
There were some areas to improve. Food stocks were very low on the inspection day. Some medicine changes and support-plan changes had not been recorded in every relevant place. The manager said these issues would be addressed immediately.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. It had also been rated Good at the previous inspection in November 2015, so the overall rating remained Good.
People felt safe
People told inspectors they felt safe, and relatives were confident that staff understood and managed risks. Staff knew how to report abuse and support people during periods of anxiety or difficult behaviour.
“People remained safe because they were supported by staff who knew how to recognise abuse and understood their role and responsibility in protecting them from avoidable harm.” from the report
Kind and respectful staff
Staff treated people as equals and responded with patience and reassurance. Inspectors saw positive communication and support for privacy, dignity and independence.
“We observed staff treated people with respect and as equals and they showed an interest in what people were doing and had to say.” from the report
Personalised support
Care plans covered people's health needs, preferences, routines, communication and cultural needs. People and relatives were involved as fully as possible.
“People received care and support that was personalised and responsive.” from the report
Activities and community access
People were supported to take part in activities and hobbies they chose, including trips, holidays, shopping, swimming and community activities.
“Social inclusion was very much promoted and people had access to information about local attractions and events.” from the report
Open leadership
Relatives, staff and professionals spoke positively about the manager. The home used regular audits, meetings and surveys to check quality and identify improvements.
“There was an open and transparent culture in the service where people were listened to and staff were valued.” from the report
Low food stocks
needs fixingFood stocks were very low on the inspection day. The manager said food management would be reviewed to make sure enough food was available at all times.
“We were concerned that the food stocks should be better managed to ensure there were sufficient foods available at all times.” from the report
Medicine records
needs fixingA sample medicine stock check found one recording issue. Recent medicine changes were not documented in all care records, and body maps were not being used for topical creams.
“We found recent changes to some people's medicines had not been documented in all care records.” from the report
Support plans needed updating
needs fixingSome people's needs had changed, but their support plans did not fully reflect those changes. The manager took immediate action to update the information.
“We identified some examples where people had experienced some changes with their support needs but their support plans did not fully reflect this.” from the report
- 01How do you now make sure there are always enough food stocks for people's needs and preferences?
- 02How are medicine changes recorded across all relevant care records?
- 03Are body maps now used to show where topical creams should be applied?
- 04How often are support plans checked after a person's needs change?
- 05How will you support my relative to choose activities and access the community?
This was a comprehensive, announced inspection covering all five rating areas, with feedback from people, staff, relatives and professionals and checks of care and management records. This explanation was written from the published report of 23 January 2018 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 Mapperley Lodge
3 rated inspections over 8 years: the service has held its Good rating throughout.
- January 2024Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2014Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not ratedCaring: Inspected but not ratedResponsive: Inspected but not ratedWell-led: Inspected but not rated
- September 2014
Report published without a new overall rating.
- September 2013
Registered with the Care Quality Commission on 18 September 2013.
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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