Maple Leaf Lodge Care Home

Updated 16 February 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 included checking the provider was meeting COVID-19 vaccination requirements. 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

The inspection was carried out by two Inspectors 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 Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager who was applying to be registered with the Care Quality Commission. This means that the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

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 to 19 relatives about their experience of the care provided. We spoke with 15 members of staff including the regional manager, manager, deputy manager, head of care, senior care workers, care workers, activity coordinators, housekeepers and domestic staff.

We reviewed a range of records. This included three people’s care records and multiple medication records. A variety of records relating to the management of the service, including policies and procedures were reviewed.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 16 February 2022

About the service

Maple Leaf Lodge is a residential care home providing accommodation for persons who require nursing or personal care to up to 67 people. The service provides support to older people living with a dementia and or a physical disability. At the time of our inspection there were 37 people using the service.

Maple Leaf Lodge accommodates up to 67 people in one adapted building, on three separate floors. One floor specialises in providing care to people living with dementia.

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

Significant improvement had been made following the last inspection. The provider had reviewed and developed systems to monitor the quality and safety of the service. We found effective oversight and quality assurance processes in place which significantly reduced risk to people.

A variety of effective audit systems were demonstrated to monitor the quality of service people received. The provider had action plans in place demonstrating plans for continued improvement and how they could sustain this.

People received their prescribed medicines. Staff demonstrated understanding and knowledge of people’s healthcare needs.

There was significant improvement in Infection Prevention and Control (IPC) processes. The home was visibly clean, and areas had been renovated improving safety. The provider had systems in place to monitor IPC and COVID-19 measures in the home.

Staff were delivering person centred care, Interactions between people and staff were positive and engaging. People were receiving respectful and dignified care that met the needs of the person.

Staff spoke positively about the changes and improvement’s in the service. They felt supported by the management team. Relatives also felt the service had improved and their relatives continued to received good care.

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.

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

Rating at the last comprehensive inspection on 23 June 2021 and update

The last rating for this service was inadequate (published 25 August 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 25 August 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on actions we told the provider to take at the last inspection.

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. This included checking the provider was meeting COVID-19 vaccination requirements.

The overall rating for the service has changed from Inadequate to Good based on the findings of this inspection.

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