Maurice House

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 assessment we rated this key question Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. A relative told us staff had met with them upon their request to discuss how to reduce the falls their family member was having. They said, “We were satisfied with the outcome (of the meeting). Staff were eager to put forward suggestions.”

Accidents and incidents were documented, with senior staff adding any relevant supplementary information to the report. The registered manager then reviewed the report to confirm that all necessary actions had been taken before signing it off.

The registered manager also held a learning log, ensuring that accidents and incidents were discussed during daily departmental meetings and staff team meetings. In addition, the registered manager carried out a monthly review of all accidents and incidents to identify patterns or trends, which helped to identify changes needed to reduce recurrence.

The registered manager worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

The registered manager had a robust process for assessing and admitting people to the service. Everyone moving in was a veteran or the spouse of a veteran. The registered manager explained, “We talk about new admissions and assessments in our daily departmental meeting. Most people come for a show around and to get the feel of the place. In the lodge (which was dedicated to people living with dementia) we would only have an admission every 4 days or so, as it often takes a while for people to settle.” Relatives told us they felt the move into Maurice House for their family member was a smooth transition. One told us, “Prior to mum moving in we were able to choose her room and making it as homely as possible with some of her personal belongings.”

The registered manager worked with people and healthcare partners to understand what being safe meant to them. The registered manager shared concerns quickly and appropriately.

Where incidents occurred that constituted safeguarding concerns these were raised with the local safeguarding team and CQC appropriately. Incidents were investigated fully within the service. The registered manager outlined the recent safeguarding concerns and actions they had taken in response.

Staff received training in how to recognise abuse and put this training into practice. Staff told us, “We get safeguarding training. I would tell the nurse (if I suspected abuse), then [clinical lead] or go and see [deputy] or [registered manager]. They have dealt with things I have raised (in the past)” and, “We are very hot on safeguarding here, anything out of the ordinary is reported.”

The registered manager and staff worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. People told us they felt safe. One person said, “I feel safe here because I can do my walk up and down the corridor in safety without worrying.” A relative told us, “She is protected. All the measures put in place means she is safe.” Another said, “Overall I am so very grateful that my mum is safe and being looked after by hard working, caring wonderful staff.”

People’s care plans contained detailed information for staff on how to assist people in remaining safe whilst living at Maurice House. For example, one person required a hoist to be moved, as well as a lap belt whilst in their wheelchair, together with bed rails when they were in bed. There was evidence in this person’s daily notes that staff were following this guidance and they were supporting the person to reposition to help reduce the risk of their skin breaking down.

Where people’s needs changed, their care plan was reviewed and where relevant risk assessments drawn up. This included one person who had recently had a fall and a falls risk assessment was introduced instructing staff to assist this person to mobilise where needed to reduce the risk of further falls.

Some people were diabetic and their care plans contained details of how staff could support them with a glucose controlled diet, but also promote occasional risks such as the odd, sweet treat.

People were seen to have drinks available to them when they were in their rooms and all had their call bells within reach. This helped ensure people stayed hydrated and were also able to alert staff if they needed help.

The registered manager did not always detect and control potential risks in the care environment. Although the internal environment was clean and in good condition we found some items which could pose a potential risk to people. For example, in a recently vacated room there was lighter fluid and butane gas canisters on a side table. The door was unlocked. There were also prescribed creams left unattended in this room. We alerted staff to these who moved them. The sluice room (a room for cleaning contaminated equipment such as commodes) on the top floor was unlocked and contained hazardous cleaning chemicals within reach.

In the grounds of the service there was an unlocked greenhouse which contained a canister of cleaning fluid and across the grounds sharp tools were left unguarded. At the bottom of the large garden area there was a viewing platform looking out over the fields towards the sea and we found a skip to the righthand side of this which had a pile of discarded furniture, a fridge and a heated serving counter which had the potential to cause entrapment or injury. We spoke with the registered manager about this who told us these items had been ‘fly-tipped’ and they were in the process of obtaining quotes for security cameras and a barrier to prevent access to this area.

Despite this we found generally the premises were very well maintained and tidy and we had no concerns that maintenance was not being carried out regularly. A relative told us, “Any maintenance needed to her room is done quickly.”

People had personal fire evacuation information in place, fire blankets were available and fire extinguishers serviced and safely wall mounted. Fire points were clearly marked, fire/exit ways signage and fire doors/exits were clear, unobstructed and well maintained.

Although staffing rotas showed staff levels generally in line with what we had been told, feedback from some people and review of call bell times showed at times people living in the nursing area of the service were having to wait to receive their care. We did not have any concerns about the residential area or the lodge (for people living with dementia).

There was mixed feedback on staffing levels. One person said, “I’ve never had a problem with staffing or having to wait. There is always someone around.” Some relatives said, “Staffing is fine. I’ve never not seen staff around” and, “I hear staff checking with each other to make sure the area is covered.” However, other comments we received were, “Sometimes (not often) there has been a shortness of staff on the unit at night, with only 1 carer rather than 2. Although people were not left without support if they needed it. The provider will tell me they will bring staff over from the lodge, but it concerns me this will leave them overstretched”, “We are very short of staff” and, “Staff don’t come quickly.” A relative told us, “In general it’s not uncommon to wait 20 minutes for a buzzer to be answered.”

Staff also had mixed views on staffing levels. They told us, “Most of time we have 8 with maybe one agency or flexi-bank” and, “Yes, there are enough staff. We have enough time to do everything we need to and spend social time with people. The afternoon is a good time for that.” But we also heard, “Numbers are sufficient, but think new staff need greater support. We have increasingly complex residents with some people on the resident floor with nursing needs. Management are aware of the pressures”, “There are times when people have already been incontinent by the time we get to them” and, “Staffing levels are sufficient to meet the needs of people, though occasionally we are short staffed.”

We reviewed the call bell log between 4 and 18 July 2025 which consisted of 443 call bell alerts of those, 235 within 15 minutes, 147 within 25 minutes, and 24 within 30 minutes. However, there were 37 call alerts that took over 30 minutes to respond to. Although the registered manager said, “Sometimes the system clashes and it doesn’t ring, so we have had to reset it. However, the panels should still show the call ringing” this did not account for a large proportion of call bells not being answered for at least 25 minutes.The registered manager told us following our inspection, “We have not moved people over from the lodge without back filling the lodge. We often have 2 care supervisors on a night in the lodge so we have moved one over and filled with a flexi-carer.” They also provided us with further detail on how deployment of staff is organised to help ensure that the service was not short staffed.

Staff went through an induction period when commencing in the role. One new staff member told us, “It was basic, but good and it was sufficient for me to feel comfortable in supporting people’s needs.” Another told us, “Really good induction. Given all the training in care, e-learning and the Care Certificate (a set of standards for people working in care). We did shadowing; I found it really useful. It’s nice to see how everyone works.”

Staff received supervision with their line manager which gave them an opportunity to discuss their role, any concerns, training requirements or progression goals. A staff member said, “I found it useful (supervision). It’s nice to be able to talk about your personal life.”

Staff were recruited through a robust process which including providing evidence of their performance at their last position, their right to work in the UK and their fitness for the role. All prospective staff underwent a Disclosure and Barring checklist (DBS) prior to starting work to make sure they are suitable to work in the care sector.

The registered manager did not always assess and manage the risk of infection. At lunchtime we observed staff serving people their food without wearing personal protective equipment (PPE) such as gloves and aprons. Staff should wear appropriate PPE, such as a clean apron and gloves when serving meals in a care home to prevent the spread of infection and ensure food safety, particularly if there is a risk of contact with body fluids or if assisting with eating.

In spite of this we had no other concerns about the cleanliness of the service and relatives agreed, telling us, “It (the home) is kept spotlessly clean” and, “Her room is always spotlessly clean and bedding changed weekly.”

The service was extremely clean and people told us they had no concerns about the cleanliness. Housekeeping staff were seen working throughout the day and communal areas were kept tidy and well-presented. The registered manager told us all of the corridors had recently been repainted and we found they were bright and free from marks or odours. People’s slings were individually labelled and clean and cleaning mops were stored appropriately and colour coded.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences and people could have pain relief if they needed it. One person told us, “I can get Paracetamol. They (staff) ask me every time I have my medicines (if I need it).”

People’s medicine administration records (MAR) were held on an electronic MAR system which alerted staff if medicines were overdue. Nurses scanned a code on the electronic system which related to people’s medicines and each record had a picture of the person together with details of any allergy.

We checked the medicine counts for 3 people and these were correct. We were told where the service had resident of the day each month, staff always carried out a full medicines stock check for that resident.

The medicine room was extremely well organised and well laid out and each locked cupboard corresponded with the same label on the key ring. The box of medicines awaiting return was not overflowing and cupboards were clean and tidy. Fridge temperatures were checked and the medicine room temperature taken twice a day.

People’s care plans were detailed with a list of medicines and how people wanted to be supported to take them. For example, ‘[Person’s name] likes to have her medications given with a spoon one at a time and will take them with water or squash’. There were also a series of steps staff went through on the electronic system to check that giving a person ‘as and when’ medicine was the best course of action.