Maple Leaf 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

Safe - this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question requires improvement. At this assessment, we assessed a total of 8 quality statements from this key question the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on opennessand honesty. Most staff listened to concerns about safety and investigated and reported safety events. However, one incident that had occurred was not managed appropriately. Sufficient steps to reduce the risk of recurrence had not taken place and the care records did not clearly reflect what had occurred. When we returned, we found that the member of staff had been supported to understand and reflect on the omissions of recording and the provider and registered manager had put robust systems in place to improve responses to risk and embed lessons learnt.

We did not find evidence of a closed culture. Where incidents or concerns had been raised the registered manager ensured that safeguarding and where necessary CQC were notified. Staff told us they were supported to raise concerns and where performance issues were identified with staff these were quickly addressed by the registered manager and where wider messages were needed this was quickly communicated to staff and people’s outcomes monitored.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People were supported to attend health clinics and access health services. One health professional told us “We have a longstanding relationship with the home, and I have found them responsive and caring.” Another health professional said, “They always take an active role in people’s care.”

One person told us they were unhappy with their care arrangements as they felt their freedoms were being restricted. The registered manager had been discussing with the person levels of support and as a result had made arrangements for a reduction in the person’s one-to-one in agreement with them. Steps were also being taken to support the person’s voice as well as working with health professionals to better understand the person’s health and social needs.

Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There were safeguarding policies and procedures and staff had regular training on how to safeguard people from abuse and what to do if they had safeguarding concerns.

The registered manager told us that the aim was to safely enable people to be active in their care and how risks were managed. We found the service to be adopting an approach to least restrictive practices. Medicines were kept actively under review with an aim to be least restrictive for people.

There were no people assessed as needing physical restraint and all staff had regular training and refreshers on non-restrictive techniques for managing people’s anxiety and behaviours.

One health professional said, “They have a made a positive difference in the outcomes for people.”

The provider worked with people to understand and manage risks by thinkingholistically. Most staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The registered manager had clear aims of achieving a service where all staff were aware and responding to people’s needs.

The registered manager was working with people who use the service to better identify what was important to them and to open up and expand opportunities for people.

People were encouraged to be a part of their care reviews and where possible to actively input into care plans and risk assessments.

The provider did not always detect and control potential risks in the careenvironment. A staff member failed to report an incident properly, delaying action to address risks. Once the registered manager was informed, they quickly improved the person's safety and implemented better systems to manage and oversee environmental risks.

People were supported to feedbackon the home environment, one person had raised concerns their room was too small, so a larger room was made available for this person.

The home environment was well maintained, and the home was currently undergoing significant refurbishment.

The provider had a proactive and positive culture of safety, based on opennessand honesty. Most staff listened to concerns about safety and investigated and reported safety events. However, one incident that had occurred was not managed appropriately. Sufficient steps to reduce the risk of recurrence had not taken place and the care records did not clearly reflect what had occurred. When we returned, we found that the member of staff had been supported to understand and reflect on the omissions of recording and the provider and registered manager had put robust systems in place to improve responses to risk and embed lessons learnt.

We did not find evidence of a closed culture. Where incidents or concerns had been raised the registered manager ensured that safeguarding and where necessary CQC were notified. Staff told us they were supported to raise concerns and where performance issues were identified with staff these were quickly addressed by the registered manager and where wider messages were needed this was quickly communicated to staff and people’s outcomes monitored.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There were comprehensive infection prevention and control policies and procedures and staff understood their responsibilities in maintaining effective infection control in the home. We observed staff wearing Personal Protective Equipment (PPE) when carrying out care tasks.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Where people had emergency medicines (PRN medicines) protocols detailing when and how to administer safely were detailed and up to date.

The provider was aware and working to the principles of STOMP (Stop Over Medicating People). This meant the provider was working with others to stop overmedication. This could include working with people with a learning disability, autism or both, their families, health professionals, commissioners and prescribers.

Medicine records were checked twice a day ensuring that they were correctly filled in and accurate, and there were weekly medicine stock counts. All staff administering medicines had received training and subject to regular competency checks.

Medicines including controlled medicines were stored and managed safely.