Maycroft 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.

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 72 (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.

Incidents and accidents, safeguarding concerns and complaints were recorded on the provider’s system. These were reviewed, discussed and analysed to determine any underlying causes or trends and to identify any actions required to improve the service. We saw evidence of learning recorded in staff meeting minutes and through their email system to inform staff of any changes or updates to their ways of working.

Staff told us they felt comfortable reporting any incidents. One member of staff told us, “We discussed lessons learnt at staff meeting and it helps us improve.”

The registered manager understood their responsibilities under the Duty of Candour. They told us, “Here at Maycroft, we are committed to be open and honesty in all aspects of care and try to keep families and residents up to date.” One relative told us, “I’ve been informed of all the changes in regards to [relatives] care and we all work together.”

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 told us they felt safe at the service. Their comments included, “I’ve been here a long time, I love it here.” “This is a nice place; staff are very kind.”

Relatives also said, “We’re really happy that we got [relative] in there, we thought it was a good home, but you never know, you see and hear about such dreadful places, but it has been as good as we had hoped. It is clean and tidy when we go in and there is plenty of staff and it seems all the same ones. We are happy that they are safe there.”

The staff team and managers told us they worked well with other professionals to provide continuity of care, including when people moved between different services. Healthcare professionals made comments such as, “Staff generally follow the advice and guidance provided by us.” “Staff are also proactive and approachable, and they are always willing to make ad hoc contact for same-day assessments or for clinical advice when required.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. 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. The provider shared concerns quickly and appropriately.

People said they felt safe from harm and abuse and relatives agreed. One person told us, “I do feel safe, but it is difficult to explain exactly why. I have a call bell, and someone usually comes pretty rapidly when I press it.” A relative told us, “[Relative] is very safe, there is plenty of staff about and I always find someone if I need them”

Staff received training in safeguarding and were aware of their responsibility to safeguard people and knew who to contact in the event of any safeguarding concerns. One staff member told us, “If I was concerned, firstly I’d make sure the residents is safe, then I’d report it to the manager or senior staff, document it. Another member of staff told “I would report to safeguarding and contact CQC.”

The provider was proactive in raising safeguarding concerns with the local authority and CQC. They worked with the relevant professionals to investigate concerns when incidents occurred.

The provider understood their responsibilities under the Mental Capacity Act 2005 in ensuring Deprivation of Liberty safeguards (DoLS) applications were submitted as required.

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 that mattered to them.

People and their relatives said staff knew their needs and met these safely. One relative said, [Relative] had been in another home that they chose themselves, but they had a few nasty falls, and a further assessment was carried out whilst in hospital and they were transferred to Maycroft and they love it. The staff are very good with them, and they have had no more falls, so I am sure they are safe here.”

There were effective processes in place to ensure risks to people were assessed and mitigated. Risk assessments were clear, comprehensive and regularly reviewed. A member of staff told us, “Our risk assessments are always person centred, we review them monthly or sooner if residents’ health conditions change.”

The provider detected and controlled potential risks in the care environment. Although they did not ensure equipment, facilities and technology supported the delivery of safe care.

People were supported in a safe and well-maintained environment that met their needs. People and relatives told us they liked the environment they lived in, although it was limited on communal space. This is due to an extension that is being added but there has been a delay for this work to commence. Relatives’ comments included, “The renovations really need to be done but that's the corporate managements fault.” “My only issue is the delay over renovation work.” “The extension is it’s just not happening, it’s very frustrating.”

The service is continuing to develop to ensure it meets the needs of people living with dementia. During our visit, we noted a lack of dementia‑friendly signage, such as signs with both words and pictures to identify bathrooms and toilets. This type of signage can significantly support people living with dementia to navigate the environment more independently.

The provider agreed during our visit, to order the necessary signage prior to the commencement of the new build.

There were effective systems in place to monitor and regularly check the safety and upkeep of the premises. The management team and staff worked together to help ensure any potential risks were identified and addressed promptly such as faulty equipment or trip hazards. Safety checks were completed regularly. They also responded promptly to any reports from the staff where repairs were required.

Equipment used to support people was suitable, well maintained and stored securely. The provider had an up-to-date plan in place to help ensure people were supported in the event of an emergency.

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.

Comments from people and their relatives included, “Staff are all very patient with [name]” “Well staff have been brilliant, that place deserves a medal, it really does, they supported my [relative] and us when we brought them in” “The staff have been so kind and patient with [relative] as their dementia is getting worse” “The staff know people very well and seem very well trained.”

The provider carried out checks on the suitability of staff before they started working at the service. Systems in place included checks on new staff’s identity, eligibility to work in the United Kingdom, Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This information helps employers make safer recruitment decisions.

The registered manager used a dependency tool to help ensure staffing levels were sufficient to meet people’s needs.

New staff received a thorough induction to help ensure they were well prepared and felt confident to care for people. The induction program included a welcome and introduction to the service and people who lived there, and training that the provider identified as mandatory, such as safeguarding, infection control, moving and handling, and health and safety. Additional training was in place which covered things such as Parkinson’s diabetes and dementia care.

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.

The home was free of odours and housekeeping staff made sure areas were sanitised, clean, hygienic and fresh. One relative said, “I see plenty of staff when I go in, they all wear their personal protective equipment (PPE) when they do things, the place is clean.”

Staff had sufficient supplies of PPE. They received training to help them maintain good standards of infection control. Staff told us they followed procedures for the use and disposal of their PPE. People and relatives also confirmed staff followed safe infection control practices.

There had been an infection outbreak in December 2025, and the registered manger had received support from the Health Protection Agency to ensure that the infection was contained within the service and people were safe.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Senior care staff were trained in medicines administration, and their competencies were checked regularly by the registered manager. Medicines audits were undertaken weekly. Where errors were identified, we saw appropriate actions were taken. Mandatory medication training including eMAR (electronic medicines administration records) proficiency training and is mandatory yearly. The system highlighted if a medicine was not given within the safe time of administration, or if someone had not received their medicine safely.

We observed the administration of medicines. Staff followed safe procedures and displayed a confident and calm manner. They communicated with people respectfully and kindly, explaining what they were doing and providing support. Consent was obtained from each person before administration. We discussed with the registered manager the medication administration timing at lunchtime as this was happening whilst people were eating their lunch. They said they would relook at the timing to enable people to eat uninterrupted.

Where people were prescribed ‘as required’ (PRN) medicines, we saw PRN protocols were in place. These were clear and contained all the necessary details about the person, the prescribed medicines and how to administer these.

Medicines were stored appropriately. Although we found that internal and external medication had not been separated in the trolley. This was addressed immediately by the senior on duty. Temperatures of the medication storage room were taken and recorded regularly and were within safe range.