Maple Cottage

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 requires improvement. At this assessment the rating has remained 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 provider was in continued breach of the legal regulations in relation to safe care and treatment.

This service scored 47 (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 demonstrate a proactive and positive culture of learning in order to improve people’s safety. The provider did not have a robust process in place to monitor or review incidents in the service. This meant it was not clear what actions were being taken to mitigate future risks to people and staff. The provider had not analysed incidents effectively to understand any underlying trends and themes. This meant they were not able to demonstrate how lessons were being learnt to ensure restrictive practices were reduced and good practices were embedded.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. We received mixed feedback about how well the provider shared information with other health professionals to ensure effective communication about people’s changing needs. People’s care plan documentation was not always up to date or detailed. This meant staff did not have accurate information about people’s needs to share with other services to ensure people received continuity in their care.

The provider did not always work well with people to understand what being safe meant to them. They did not always demonstrate how they were improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Safeguarding concerns and incidents were not always managed safely. For example, we found incident forms had not always been reviewed by a member of the management team to identify potential safeguarding concerns and safeguarding notifications had not always been made to the relevant authorities. This meant the provider was not always able to evidence how safeguarding concerns had been investigated and addressed to ensure people were kept safe.

Risks to people’s health and safety were not assessed and managed appropriately. Risk assessments were not in place for all identified risks. For example, we found staff did not have guidance in place to support them in managing risks associated with people’s health needs including their epilepsy support needs and diabetes care. Where people may pose a risk to themselves or others, the provider had not ensured there was adequate guidance for staff about how to understand and manage these risks in a proactive way to minimise the risk of distress and potential harm.

The provider did not detect and control potential risks in the care environment. At the last inspection, we identified risks relating to the provider’s fire safety monitoring and water safety checks. At this inspection, we found continued concerns with health and safety monitoring processes. Practice fire evacuation drills were not being completed for all staff. This meant there was a risk staff may not know how to respond appropriately in case of a fire to ensure people were kept safe. Fire safety system checks and water safety checks were not being completed as scheduled and records were not detailed or accurate. This meant there was a risk concerns may not be promptly identified and addressed to ensure people were kept safe.

The provider had made sure there were enough staff available to support people. However, the provider had not always ensured staff had the appropriate skills and competency to support people safely. At the time of the inspection, there was no registered manager in post and management cover was being provided by existing registered managers from other services within the organisation. The interim management team had identified gaps in staff knowledge in key areas of people’s support such as medicines management, fire safety and incident reporting. They were in the process of addressing these concerns, however improvements in staff practices were not yet embedded.

There had also been recent changes in staffing within the service and people and relatives told us this had impacted how well staff knew people and the consistency of their support. Staff had not always been provided with sufficiently detailed guidance about how to understand people’s personalised needs and preferences.

The provider had appropriate recruitment policies and processes in place to check staff were safely recruited.

The provider had assessed and managed the risk of infection. During the inspection we found the service was clean, with no significant infection prevention and control concerns identified. We found office chairs in the lounge area which were worn, with the fabric no longer intact. Managers told us they had already identified this concern and would be arranging for these to be replaced.

The provider had not always ensured medicines were managed safely and in line with national guidance. While some systems were in place to support safe practice, these were not always being followed by staff.

Medicines administration records (MARs) were transcribed by a single staff member using pharmacy labels rather than original prescriptions, without a second check. This practice did not align with Royal Pharmaceutical Society (RPS) standards and increased the risk of recording errors. Some staff had overdue competency assessments and outstanding training in medicines handling. This meant the provider could not be assured all staff administering medicines were suitably trained and competent.

Protocols were in place to provide staff with guidance about when to administer people’s as and when required medicines. However, these protocols did not provide sufficient detail about what alternative strategies should be attempted before using a medicine to support people experiencing anxiety or distress.