Maple Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 8 quality statements under the safe key question, identifying both good practices and areas of improvement. The overall rating for this key question is good. People told us they felt safe, this was reflected in feedback from relatives. Risks relating to people were assessed and bespoke plans were developed to meet people’s care and social needs. When changes occurred, plans were updated, feedback from relatives indicated they were involved and kept up to date with any events and changes to people’s care. Recruitment checks were undertaken and staff completed training prior to providing care to people. Staff spoke positively about the training they received. Processes where in place to review events that occurred across the service, this included analysis of themes to make improvements. The provider made referrals to external bodies when required, this included reporting statutory notifications to CQC. The environment was tidy. However, we identified areas of improvements were required in some parts of the home and cleanliness and wear on some equipment. Where found areas of the home environment required refreshing, the provider had already identified this as an area of improvement and work had begun. People were supported with medicines. However, we identified areas for improvement in relation to guidance for staff about people’s ‘as required’ medicines and labelling of some creams and topical lotions. The registered manager was proactive in addressing the issues we identified and immediately actioned the necessary improvements.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Relatives told us people received safe care. Where events occurred, they were kept up to date, this included any actions made to mitigate further risk to people. We were told, “They always keep me up to date.”

Staff told us they were aware of the whistleblowing policy and were encouraged to raise any concerns. Staff felt confident the management team would take appropriate action and to manage any concerns appropriately.

The provider had systems in place to identify areas of improvement through effective analysis of accidents and incidents. They used this learning to look at themes and trends to try to prevent future occurrences.

Relatives described how the provider completed assessments for people. This included partnership working with other agencies to support safe care and treatment.

Staff told us plans had been put in place to support transitions in and out of the service. This included any visits to hospital, with a pre-prepared hospital pack with key information on how the person wished to receive their care.

Health professionals confirmed staff at Maple Lodge worked well with new referrals and packages of care. We received feedback about some challenges with partnership working. However, the registered manager had worked with professionals to make improvements in this area.

Systems were in place to ensure people experienced a safe transition between services. However, we identified one person who had been discharged from hospital with a change to their medicines. Staff had not made checks to ensure the person had sufficient stocks for this change. We raised this with staff and action was immediately taken. The registered manager told us the process would be reviewed.

People told us they were safe. This was supported by the views of relatives. Comments included, “The environment is safe for [Person]” and “[Person] is safe and it's a good place to live.”

Staff received the training they needed to be able to carry out their roles effectively and to keep people safe. The provider’s safeguarding policy guided staff on how and when to raise concerns. Staff told us they felt confident the management team have the knowledge and experience to be able to safeguard people effectively.

We observed staff treating people respectfully. Staff were attentive to people's needs and spoke with them in a kind manner. People were visibly comfortable in the company of staff.

Systems were in place to protect people from the risk of abuse. Safeguarding concerns were dealt with appropriately. Staff had received safeguarding training and understood their duty to report any concerns. Managers ensured safeguarding concerns were appropriately reported, this included submitting statutory notification to CQC where required. Any further actions required, and outcomes were recorded.

Relatives told us any risks to people were assessed and staff worked with people to manage any identified areas. A relative told us, “[Person] can be difficult, and they manage this very well.”

Staff told us robust assessments were completed to mitigate risks and assessments were regularly updated by the management team.

We observed staff using safe practices when assisting people. Staff communicated clearly and explained the care they were providing to ensure the person was comfortable and felt safe. However, during our assessment we found some bathroom doors were locked. One staff member told us this was for safety purposes as people could slip however, the floor was not wet. We raised our observations with the registered manager to review, to ensure people had free access to bathrooms without having to seek assistance of staff. When we checked on a different day, all bathing areas were unlocked and fully accessible.

Risks to people had been appropriately assessed. Where appropriate, care plans had been implemented to mitigate risk. Some people required the use of equipment to keep them safe, such as moving and handling aids and pressure relieving mattresses and cushions. These were always available for people and safely maintained. When a person required specific monitoring or actions to be taken to keep them safe, such as regular repositioning in bed or monitoring of food and fluid intake, care records were detailed and well maintained.

Relatives described a safe living environment for people. They spoke approvingly of people’s access to equipment to support with mobility and comfort. Where people had access to call bells to alert staff support was needed, we received mixed feedback over people’s understanding how this was used to access care from staff. However, during conversation with people, where call bells were pressed, staff responded promptly to the person.

Staff told us they have received training in areas of health and safety. They were able to demonstrate an awareness of safety procedures and their responsibilities around ensuring any hazards were removed promptly. One staff member told us “The staff team ensure the home is free of clutter and equipment is stored away safely.” This included monitoring the lighting in the home, so people could move around safely.

Areas of the service required redecoration. This had already been identified by the provider, decorators were on site during our assessment freshening up the environment. Several wardrobe fixings had come away from the wall, this meant they were not secure should a person pull on them. This was immediately resolved by the maintenance officer when raised. On the first day of the assessment, we identified a lack of storage, and some areas were cluttered. Continence aids were stacked in people’s bedrooms, and wheelchairs stored in the corner of one lounge. During our visits, these issues were addressed, and items appropriately stored.

Routine checks on the environment and equipment were up to date and certificates were in place to demonstrate this. A grab bag was available within the reception area. This contained important up to date information and equipment should people need to be evacuated in an emergency. A recent audit identified other planned improvements to the environment such as directional signage to assist people who were new to the home or who lived with dementia.

People and relatives acknowledged staff to be skilled and compassionate in providing care to people. We were told, “[Staff] are marvellous, they look after people very, very well.” We received some feedback from relatives who gave mixed views over staffing levels, with some comments indicating staff levels could improve. Comments included, “Staff is sufficient however, sometimes there isn’t (enough)” and “They [Staff] get no respite, I don’t think there is enough.”

Staff told us they had an induction at the start of their employment and were equipped to carry out their roles effectively. Staff were able to tell us where risk assessments for each resident could be accessed and viewed. Staff told us there were enough staff to provide safe and effective care. However, we did receive some feedback that staff levels could be improved. Comments included, “Staff levels are adequate” and “Sometimes it can feel as though there aren’t enough staff on and sometimes it feels like there are more than enough.” One staff member told us, “We utilise agency staff when needed and we have a good relationship with the agency.”

We observed there were enough staff on duty to meet people's needs. Staff were always present in communal areas to respond to people in a timely manner when they requested assistance.

Recruitment procedures were safe. Checks were carried out on all staff before they started employment. Systems were in place to identify the number of staff needed on duty, based upon people’s care needs. Rotas reflected the assessed staffing levels. Staff received an induction when they started in their role, this included agency workers. Training was appropriate to enable staff to deliver safe care and ongoing supervision was available for staff to discuss any learning needs.

People and relatives spoke approvingly of the cleanliness of the home. We were told, “Its clean and tidy,”

Staff knew the actions to take in the event of an infectious outbreak. They confirmed they had received training and were able to describe how they would adapt their practice. For example, when safely handling soiled or infectious laundry. One staff member told us, “Wearing the right PPE and regular handwashing is vital.”

We observed the home was generally clean and tidy however, some areas needed some improvement. One lounge had a small kitchen serving area. This needed a deep clean to ensure some non-food items were removed from the cupboards. Tiling around the sink in the medicines room needed to be replaced and the enamel on a bath had been damaged by a chair seat. Some commodes and bins around the home needed to be replaced. We raised the above issues which were immediately addressed, and new equipment was ordered. Staff had access to personal protective equipment (PPE). Bathrooms were well stocked with hand wash. Foot pedal bins were in operation. Signage describing good hand hygiene techniques was displayed.

Systems were in place to protect people from the risk of infection. Staff received training, had access to detailed policies and procedures and cleaning schedules were maintained.

People were supported with medicines. Staff kept relatives informed of any changes.

Staff told us they have received training to manage medicines safely. Staff were able to demonstrate their understanding of the correct actions to be taken if any errors were to occur.

Systems were in place to ensure people received their medicines and allergies were clearly documented. Staff received training and had regular observations made on their competency to administer medicines. However, we identified some improvements were needed. For example, some ‘as required medicines’ needed clearer protocols to guide staff about when a person may need the additional medicine. One person had additional pain relief prescribed but the protocol did not state when this should be offered. Another person had two types of pain relief medication however, the protocols did not describe what each medication had been prescribed for. Staff did not always record the date topical lotions and creams were opened, in line with best practice. We raised these issues with the registered manager who took immediate action to address this.