Maple 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 assessment we rated this key question inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of the legal regulation in relation to safe care and treatment and safeguarding service users from abuse and improper treatment. Improvements were found at this assessment and the service was no longer in breach of this regulation. Staff now assessed and mitigated risks and people had thorough support plans to guide safe practice. They now had systems to protect people from abuse and there were enough staff to ensure people’s safety and meet their needs. Renovations to the service had taken place and we observed people were benefitting from living in a comfortable and homely environment.

This service scored 75 (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 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.

The registered manager had an overview of all accidents, incidents and complaints which had been responded to or investigated where required. When an incident had occurred, the service was open and transparent with people, their relatives and staff. Lessons learned were shared with staff to continually identify and embed good practice. This included the use of appropriate restraint, safeguarding people from harm and ways to decrease people’s distress.

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’s needs had been fully considered when they were supported to access different services including medical appointments and admissions to hospital. People’s support plans were up to date and included communication plans and a hospital passport. These included clear guidance to share with other health and social care professionals. We were able to see the support people received when they found some health care procedures difficult as multidisciplinary meetings were held to discuss all options.

The registered manager made referrals to appropriate health and social care professionals when required and in a timely way. This included referrals to opticians and dentists, occupational therapy and psychotherapy.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve it. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Concerns were raised quickly and appropriately.

At the last assessment we found incidents which had not been reported to the local authority or the care Quality Commission (CQC). This meant these incidents were not fully investigated or shared for transparency.

The registered manager had introduced a robust safeguarding system which focused on people’s health and safety. Concerns were raised, investigated and referred appropriately to the local authority and CQC, quickly and appropriately.The registered manager analysed safeguarding concerns to identify themes and trends, learning from them to reduce the risk of reoccurrence. For example, after each incident, staff were debriefed, support plans amended as to new ways of working to better safeguard people and refresher training put in place for staff. Investigations also involved people and their family members using pictures and symbols to support communication and understanding of the event which had occurred.

People were safe living at Maple Lodge with the staff who supported them. A family member said, “[Relative] is happy and safe with the staff, and the people who live there. Another family member told us, “Oh yes, [Name of relative] is doing fine, and they keep us updated on anything they’re doing, and any safeguarding issues.”

Staff had received online and face to face training in safeguarding people from abuse. Staff understood their responsibilities to report concerns about abuse and whom to report to. They felt confident the registered manager would take the necessary action. A staff member told us, “I am very clear on where safeguarding referrals go and when we raise them. The system is so much clearer now.” Another staff member said, “I have not personally had to raise a safeguarding concern, but I am fully aware of the procedures and confident in the process to follow if the need arises.”

At the last assessment, staff had not received training in the use of physical restraint. Physical restraint involves any direct physical contact where the intention of the person intervening is to prevent, restrict, or subdue movement of the body, or part of the body of another person. Staff were now trained and aware of how to carry out physical restraint should they need to use it. The registered manager told us there had not been any incidents requiring the use of physical restraint since a person moved from the service earlier in the year. A staff member told us, “I have done restraint training, but I haven't used it in actual practice yet.” Another staff member said, “People have not needed any restraint, as we use redirection and distraction and other interventions when we need to.”

There was a process in place which documented safeguarding concerns and deprivation of liberty safeguards (DoLS). Evidence demonstrated conditions linked to people’s DoLS had been actioned and all information was recorded. The registered manager notified CQC when DoLS had been authorised for people.

The provider 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 which mattered to them.

Support plans and risk assessments were reviewed regularly to ensure they remained current and reflective of people's needs. Staff knew people well; they were able to tell us about associated risks to people and how they managed those risks. The support plans recorded people’s needs and the risks associated with them having a healthy and independent life including personal care, health needs, social and leisure activities and accessing the community. There was a balanced and proportionate approach to risk that supported people and respected the choices they made about their care. Some risks to people were carefully managed to alleviate distress and anxiety.

People and family members were actively encouraged to engage in discussions about the risks associated with their care and support, promoting a collaborative and person-centred approach. A family member told us, “For reviews, they have done Zoom calls with us in the past as we can’t often get there. It’s so long since [name of relative] has lived there, but we’re still involved.” Another family member said, “The deputy does a newsletter each month about [name of relative] and it’s a nice thing to get.”

People’s positive behaviour support (PBS) plans were comprehensive and well-detailed. They included observations of changes in individuals’ communication styles, which could signal shifts in mood or emotional state. This enabled staff to identify early indicators or potential triggers and respond proactively using therapeutic techniques, thereby supporting emotional wellbeing and reducing the likelihood of escalation.

The provider’s electronic management system enabled information to be monitored and updated more effectively to manage risk. Staff could access and record information quickly using the system. There was a consistent team of permanent staff to support people which meant staff knew people well and were aware of any associated risks relating to their care and support. A staff member told us, “All support plans are stored on Log My Care, which is an efficient system that makes it easy to access and update information. Any changes in care are quickly recorded, ensuring people receive consistent and accurate support.”

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. People lived in a safe, comfortable and well-maintained service which met their needs.

At the last assessment, the provider did not have effective arrangements in place to monitor and mitigate the risks in relation to fire safety. This included issues regarding fire drills, fire warden and fire marshall training and lack of personal emergency evacuation plans (PEEP). The purpose of a PEEP is to give staff and emergency service personnel critical information on the evacuation needs of each person in the event of a fire emergency.

Fire safety arrangements had been improved. Fire drills had been undertaken both day and evening and were recorded as to time, date, people and staff involved, time taken to evacuate the building and any lessons learnt from the procedure were discussed with the staff. People had been involved in the risks associated with fire safety and staff used communication tools such as easy read, pictures and symbols to support people in understanding what they should do in the event of a fire.

Staff had specific fire warden roles and responsibilities and there was a fire warden on each shift. Training had been provided for staff and fire drills showed their competence at carrying out their roles to assist and guide people, staff and visitors in such an event. All information we saw was clear and accessible should staff need to use it in the event of an emergency.

Individual PEEP's included information relating to the person’s ability to evacuate safely during a fire and any triggers from the impact of the fire alarm being sounded. The emergency grab bag contained all the relevant and necessary information needed, including a specific piece of equipment 1 person needed to ease their distress.

At the last assessment the service had not been well maintained and posed a risk of infection to people living there. People now lived in a clean and safe environment. All rooms had been redecorated, with new furnishings, new flooring fitted, bathrooms and the kitchen repaired. Peoples' rooms were personalised and contained things important to them. A family member said, “I see how it has changed, and the home has been redecorated.” Another family member told us, “The place was redecorated, and [name of relative] bedroom was redone and is nice and cosy now.”

The safety of the premises, personal spaces and the living environment were checked and managed to support people to stay safe in their own home. Where people with epilepsy and at risk of having seizures at night, cameras were used appropriately with the necessary best interest decisions made to enable staff to keep them safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff available at Maple Lodge to support people safely and meet their current care and support needs. People had 1 to 1 support to enable them to live their lives to the fullest which included going out shopping, social and leisure activities and health appointments with the support of staff. Occasionally staff were expected to work across the providers other services which had an effect on consistency. Despite this, the rota arrangements were well managed and the registered manager utilised bank staff in the event of staff sickness and annual leave. People experienced continuity of care, for example being supported by a regular staff team, and care was delivered through an agreed and individual routine. A family member said, “They sometimes have to get agency staff but try to keep normal staff on as much as they can. [Name of relative] has got a 1 to 1 and knows everybody anyway. They have two key workers in case one of them is off.”

Staff were supported in their role. This included induction, supervision, competency checks appraisal and support to develop their skills and qualifications. Staff received training appropriate and relevant to their role which covered all areas of supporting people with their physical, emotional and mental health needs. Training was monitored and refreshed at regular intervals to maintain knowledge and skills in line with best practice. A staff member told us, “Training opportunities at Maple Lodge are regular, relevant, and practical, which helps me carry out my responsibilities more effectively.”

Staff had completed the Tier 1 Oliver McGowan Mandatory training (the standardised training for health and social care staff) and the registered manager and deputy manager the Tier 2 level. The registered manager told us they were trying to book all staff on the Tier 2 course but in the meantime, they would cascade their learning to staff through dedicated sessions whilst they wait for courses to become available.

Staff spoke positively about working at the service and did not raise any concerns regarding staffing levels. Comments included, “It’s pretty fine with staffing now and we have back up staff to cover if needed. Staff are allocated to a person as all 1 to 1 and we make sure they are supported” and “Staff feel very supported and inductions for new staff are planned carefully” and “We have regular supervision, and competency checks every other month, and it provides helpful guidance and ensures quality care.”

Recruitment processes were safe. The registered manager was aware of the legal requirements when recruiting staff. Recruitment processes in place included the completion of appropriate pre-employment checks such as identification, references from previous employers, visa and immigration and disclosure and barring service checks (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

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. At the last assessment, there were no effective controls or monitoring in place for the risk of Legionnaires disease.

Safe systems and practices were now in place and monitored effectively. Face to face training had been provided to staff for identifying Legionnaires disease. We saw a water hygiene risk assessment and audits were up to date for flushing hot and cold taps, infrequently used outlets and shower head cleaning. A staff member told us, “A person came out to train us, we have dedicated staff who check the water.” Another staff member said, “We have 2 infection control leads who have completed training and they audit the whole service. This is overseen by the management team. This is added to our home improvement plan.”

Health and safety policies and procedures were issued to staff and discussed at staff meetings. Risk assessments were detailed for staff to follow to prevent the spread of infection. There were cleaning schedules in place which staff followed, and people were involved in cleaning their rooms with staff support.

Staff had access to personal protective equipment (PPE) and confirmed they had received training around infection prevention and control. A staff member said, “PPE is purchased in bulk, stored safely, and always available when required. Staff are supported to use PPE consistently and correctly, in line with infection control guidance, ensuring the safety of both people and staff.”We observed the service was clean and well maintained. People and staff had a bright and safe environment in which to live and work.

The provider made sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.At the last assessment, we found PRN (as required) medicines were being given for people experiencing distress, but information relating to these incidents was not being recorded appropriately.

Medicines administration had been improved. People received their medicines safely and as prescribed. Staff followed person-centred approaches to medicines administration, with individual medicine profiles in place that reflected people’s preferences and needs. PRN (as required) protocols were in place and provided staff with the relevant information they needed to administer these medicines safely and record their use. Fire risk assessments were completed for paraffin-based skin products and were found to be in place for all relevant prescriptions.

Medicines were stored appropriately. Staff recorded medicines administered on paper records. When these were transcribed staff weren’t always following best practice to ensure two people prepared the documents and they used the pharmacy labels rather than prescriptions for the instructions which could lead to potential errors. We raised this with the registered manager at the time of the assessment, and they told us they would implement this immediately.

Where medicines were administered covertly (hidden in food or drink), this was supported by completed capacity assessments and best interest decisions. Staff were knowledgeable about the people they supported and demonstrated the understanding to meet their individual needs and preferences when managing medicines. A staff member told us, “My recent training was managing medicines in care homes course. For me, taking this training is a huge thing because I can improve my job performance. It gave me more knowledge, and confidence regarding giving medicines.”

Medicines audits were completed weekly and included checks on stock levels, expiry dates, and usage. A staff member told us, “We have medicine leads who have done a higher level of training, they will do competency and medicine audits. Management oversees the processes to ensure everything is in order.” Staff followed robust procedures for managing medicines during social and home leave, including sign-out records and labelling. Medicine reviews were completed with GP involvement and included physical health checks and side effect monitoring.

Staff had access to support from a range of healthcare professionals, and support plans were in place for people with complex needs, including epilepsy and anxiety. A family member said, “Everything is good with staff knowledge, and I don’t have concerns about the way they give [name of relative] their medicines.”