Maplebrook Care Home

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.

This is the first assessment for this service. This key question has been rated requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation 12 and 18 relating to people’s safe care and treatment and staffing.

This service scored 53 (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 did not always have a proactive and positive culture of safety based on openness. Lessons were not always learnt to continually identify and embed good practice.

Records showed, and the registered manager confirmed, staff had not always received the required training to manage safety events where people became distressed.

Furthermore, where incidents had occurred, safety events were not always fully reported, documented, analysed and escalated to support understanding and learning. For example, information relating to safety events had either not always been documented or had failed to provide relevant information relating to how incidents had occurred, how staff had responded and failed to detail where there had been learning opportunities. In cases where learning was recorded, this did not always result in the effective mitigation of risk.

When we spoke with staff, not all staff were able to tell us what information they needed todocument in relation to safety events and where this information needed to be detailed.

When we spoke with leaders about this, they informed us what safety event processes were; however, they told us it was not always followed by staff and acknowledged, “There’s still work to do regarding the review of accidents and incidents.” This meant people were at risk of safety events not being appropriately managed.

The provider did not always ensure safe systems of care. They did not always manage or monitor people’s safety.

Effective systems were not in place to ensure safety was consistently and effectively monitored and managed at the service. For example, as reported elsewhere under Safe, some safeguarding, safety events, staffing and equipment risks had not been identified or acted upon to ensure people were consistently safe. This meant people were exposed to avoidable risk.

No concerns were shared with us by people or relatives in relation to the transition process for people before they moved to the service. The registered manager explained this process which included obtaining information regarding people’s care and support needs so this information could be reflected in their care records. People and relatives mostly informed us they were not involved in care planning processes, and we found people’s care plans and risk assessments did not always accurately reflect their needs and risks.
 

The provider did not always concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, discrimination, avoidable harm and neglect.

We viewed safety event records which showed people had been exposed to risk and harm. However, these incidents had not always been effectively reviewed by leaders, which could have supported understanding and learning of such events. This meant there was an increased risk of recurrence of such incidents, which exposed people to avoidable harm.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service and found people had up-to-date DoLS authorisations in place.

We observed people’s bedrooms doors automatically locked when closed. When this was discussed with the registered manager, they told us this was to prevent people from walking into other people’s bedrooms, which could negatively impact on people’s emotional wellbeing. However, for people whose needs meant they were provided care in bed or who were unable to independently mobilise to open their bedroom doors and / or use their call-bell to request staff support, we found they did not have mental capacity assessments which detailed this restriction, in addition there was no documented information which identified potential risks associated with this arrangement or how these risks could be mitigated.

There was a safeguarding policy in place, records showed that staff had completed safeguarding training. Staff were able to tell us the action they would take if they had concerns. The provider also told us how safeguarding concerns would be reported to the local authority so they could be investigated.

People did not raise any concerns about feeling unsafe, with 1 person telling us, “I feel safe here.” Relatives also told us they felt their family members were safe, with 1 relative telling us, “I go home with peace of mind that [my relation] is safe.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that ensure people were safe.

We found people’s care plans and risk assessments did not always provide information which accurately reflected people’s needs and risks. For example, we found people’s behaviour care plans and risk assessments did not always provide information which detailed how staff could support people in the event of them becoming physically aggressive towards others. We also found people’s care plans and risk assessments failed to accurately detail people’s health conditions, including people that had a diagnosis of diabetes. When this was discussed with the registered manager, they did not always demonstrate an awareness of people’s needs to ensure they provided clear and accurate guidance to staff. For example, they were unable to provide information which clarified the number of staff people required to support them at various times, nor the kind of situations the use of physical restraint may be considered as an intervention by staff and what this might look like in certain circumstances. This meant there was not always guidance for staff on how they could keep people safe, which exposed people to risk of harm.

However, some of the information staff told us about people’s needs demonstrated good awareness of the risks associated with people and how these could be supported. For example, 1 staff member told us how staff provided a person with time and space if they were reluctant to be supported with their care needs.

The provider detected and controlled potential risks in the care environment. They made sure facilities and processes supported the delivery of safe care.

The environment was clean and well-maintained. Effective arrangements were in place to monitor the safety and upkeep of the premises, bringing in professionally qualified people to complete environmental and equipment checks. The service employed maintenance staff who worked with leaders to ensure the home was safe for people to live in. The atmosphere and appearance of the home was homely, and people appeared comfortable and relaxed in their surroundings.

However, we did observe a shortage of equipment, such as wheelchairs, for people to use when needed. Relatives also raised this with us, with 1 relative saying, “My only minor complaint is the lack of wheelchairs.” When this was discussed with the provider, they took prompt action to obtain additional wheelchairs for the service.

The provider did not make sure there were enough skilled staff and that they received effective development to provide safe care that met people’s individual needs.

People were not always supported by appropriate levels of staffing, which impacted on people’s individual needs being met. For example, we found people waiting for a meal and for essential equipment to meet their physical and mobility needs. The registered manager informed us what staffing levels should be on each floor of the service; however, information we viewed from staff rotas did not always reflect this – with staffing levels on one floor being consistently below what we were told should be the case.

Staff also told us that staffing levels were not always adequate, with 1 staff member saying, “I would like to have more staff”, and another telling us, “There are not enough staff to do our duties.”

The required staffing levels detailed within some people’s care records was unclear and contradictory, and when this was discussed with the registered manager, they were unable to provide clear information to clarify the situation.

There was not a clear and systemic approach to determining the number of staff required on duty to meet people’s care and treatment needs. The dependency assessment tool we viewed contained information that was inaccurate, incomplete and did not reflect people’s current needs and conditions. For example, the assessment detailed one person mobilised unaided, despite them requiring support to use a hoist, and another person was documented to have food and drink unaided, despite requiring support with a Percutaneous Endoscopic Gastrostemy (PEG). Staff also told us they had concerns with the dependence assessment tool in place, with 1 staff member saying, “I don’t think the mental health aspect [of people’s needs] are taken into consideration; staff need to spend time with and listen to people.”

Failure to ensure there were enough staff on duty meant people were placed at risk of harm.

People were not always supported by appropriately trained staff, which impacted on people’s individual needs being met. The staff training matrix showed staff had not received training in health conditions, behavioural management and medicine competency which were relevant to people’s individual needs. While some people had a diagnosis of diabetes and epilepsy, and another person required essential support with a PEG, most staff had not received training in these areas. Some people’s emotional needs meant staff required training in how they could de-escalate and use physical interventions to protect themselves and others from potential harm, however, not all staff had received this training. We also found staff who were responsible for handling and administering medicines had not always received a medicines competency assessment. Meaning the provider could not be assured staff had the skills and knowledge to manage medicines safely.

Staff also informed us that they were not always adequately skilled and trained, with 1 telling us, “Staff need to be experienced. We had very good staff before and have new staff now - we are struggling. We need more experienced trained staff.” Another staff member told us, “Staff come from other care homes, but this is a complex setting, and I don’t think some staff are skilled in this area. Staff need more educating.”

Recruitment records we viewed demonstrated that safe and robust recruitment practices were being carried out.

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.

We found the service clean, tidy and well-maintained, and staff wore appropriate protective personal equipment (PPE) when supporting people to help protect them from transmissible infections.

Safe systems were in place in relation to infection control. The provider ensured staff had access to PPE and were trained in its use. The provider’s infection prevention and control policy was up to date. Information about the risk of infection was shared appropriately with people using the service and visitors.

Relatives were also happy, with 1 informing us, “The home is lovely and clean - we visit regularly and have never seen it any different.”

The provider did not always make sure that processes to make sure medicines were safely given were effective to meet people’s needs. Staff received training in safe medicines management; however, not all staff who handled medicines had received a medicine competency assessment.

Where people were prescribed ‘as required’ medicines, guidelines were in place to ensure they were given consistently and when needed, although some of these lacked detail. Which meant staff did not always have clear guidance to administer these medicines safely and appropriately.

People who required their medicines to be given to them covertly did not always have this detailed in a mental capacity assessment. Covert administration of medicines is when medicines are given in a disguised form without the knowledge or consent of the person. This meant we could not be assured that people were always being provided their medicines safely and in accordance with best practice and guidance.

A medicines policy was in place, and there were some processes to ensure medicines were received, stored and disposed of safely. Our observations and records showed people received their medicines as prescribed.

People did not raise concerns with how they were supported with their medicines, with 1 person telling us, “The staff give me my tablets; they are the same time every day - there have never been any missing or forgotten.”