Maple Leaf House

Updated 19 November 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors, a specialist nurse advisor and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Maple Leaf House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Maple Leaf House is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 2 people who use the service and 11 relatives of people. We spoke with 14 staff, including the registered manager, area manager, deputy manager, care workers, kitchen staff and domestic staff. We carried out observations of communal areas. We reviewed a range of records including 5 people's care records, 6 wound records, medicine administration records and some records relating to the management of the service.

Updated 19 November 2022

About the service

Maple Leaf House is a nursing home providing personal and nursing care to up to 48 people. The service provides support to older people and those with dementia. At the time of our inspection there were 45 people using the service. The home is purpose built to support people with living with dementia. It accommodates people on one floor with three wings, with a number of communal lounges, dining areas and quiet spaces. People have access to a secure outdoor space.

People’s experience of using this service and what we found

Records in relation to medicines were not always completed and best practice guidance in relation to medicine disposal was not always followed. People's risk assessments were not always reviewed following changes in their needs, such as after an incident. There were enough staff to meet the needs of the people using the service, however increased use of agency staff had impacted on the service providing person centred care and support. The home was clean and well maintained. Safeguarding processes were robust and ensured people were protected from the potential risk of abuse.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Actions to improve the service or mitigate risk were not always effective. People's care records were not always kept up to date. The provider had not managed the impact of increased use of agency staff on the people’s care and support. The culture within the service was not always positive; staff and relatives did not always feel communication with management was effective. The registered manager was open and transparent, understood their regulatory responsibilities and engaged with the inspection process. The service demonstrated joined up working with a range of professionals.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 8 October 2019).

Why we inspected

We received concerns in relation to the management of medicines, staffing and people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Maple Leaf House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safety and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.