Maypole Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of the legal regulation in relation to governance at the service.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have clear responsibilities, roles, systems of accountability and good governance.

We found multiple shortfalls and the issues we noted were not always documented as identified. For example, although the provider had put in place processes for better oversight of wound management, we identified inconsistencies with the standard of wound photographs. Although the provider had put in place daily huddles for nurses and care staff, the issues we noted with position change charts not reflecting care plan guidance had not been identified. Although weekly clinical risk reviews took place, these had not identified the ongoing risks to people around skin integrity. Although medicine audits took place, unlocked thickener storage boxes had not been identified, or addressed by staff. The provider was not aware of people’s poor experiences in relation to staffing levels until we informed them. The lack of dementia friendly signage had been identified by the new manager and action had been taken to address this.

The provider carried out a range of audits and checks. We saw records of monthly metrics checks which included pressure ulcers and weight loss for example. There was a daily meeting between nurses and care staff to review people’s needs and any concerns so that action could be taken the same day. Care staff told us they found these meetings useful to understand about people’s changing needs.

There was an improvement plan in place which showed actions underway. The manager told us how they assured themselves staff training was up to date alongside reviewing night staff knowledge. They told us they had introduced a checklist with all clinical staff to highlight any training needs. Regular spot checks were carried out, including unannounced night checks. A satisfaction survey was about to be launched which the manager hoped would show improvements had been made based on previous feedback from people and their families.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.