Mapleford Nursing home

On this page

• 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 requires improvement. At this assessment the rating has changed to good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were positive about the management and support they provided. Comments included, “I am happy no concerns.”

The registered manager, senior team and staff discussed the work that had taken place to make improvements in the service. A staff member told us of improvement since our last inspection. They said, “The home (service) feels much safer, staff are much happier, staff feel supported and able to bring in new ideas, there is good leadership throughout.”

An action plan was in place and was being updated to reflect where improvements had been made and next steps to continue to drive improvements in the service. Regular news letters were published and available for all to access in the entrance to the service. A range of topics were recorded including good news stories, staff updates, celebrating staff success and activities.

Up to date policies and guidance was available for the staff team to support the delivery of care to people.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff were positive about the registered manager and the support they provided. Comments included, “I am happy I feel supported if needed, [registered manager] is ok she will sort problems” and, “[Registered manager] is great and very supportive.”

A range of policies and guidance was in place. These were up to date and included links to national guidance, these had been developed by a specialist company and adapted to reflect the service. The registered manager told us they were able to check the staff had read the policies and the system provided alerts when policies have been updated.

There was evidence of management meetings being undertaken. Records included the dates of these and the topics discussed including areas to support drives for improvement.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us the management of the team engaged and involved them. Records we reviewed confirmed regular team meetings were taking place with all staff grades. Records included the topics discussed, staff told us these were taking place and that they were able to bring their views to these meetings. One said, “[Nominated individual] and [registered manager] are always updating us on improvements to the home, we have general staff meetings after CQC inspections or safeguarding to discuss things.”

Staff told us the service had provided staff with surveys to seek their views. This would help to support staff in ensure their views were listened to.

The service had their vision and values on display as well and celebrating staff in employee of the month awards to members of the staff team in the communal areas. Policy to support staff well being and equality and diversity was in place and up to date. This provided staff with information about how to support their diverse needs.

Supervision records confirmed staff were receiving supervisions, a timetable for these was in place which demonstrated staff were able to discuss their working day and areas for development.

A range of satisfaction surveys had been completed that enabled the management to act on people and relatives views to make improvements. A system was in place to deal with compliments and complaints, whilst records included feedback as a result of these we discussed with the registered manager more effective ways to provide feedback to people who have raised concerns.

Records of correspondance following the last inspection confirmed the registered manager adopted an open and transparent approach with people and relatives about the finding from the last inspection and their plans to make improvements.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff confirmed they had undertaken relevant training to support them in their roles and providing care to people. Staff told us they were happy working in the service and most were positive about the staff and working together, but not all. One said, “I am treated well as a staff member.” However another told us, “I feel some of the staff need to take more pride in their work, all types of staff.” We saw staff engaging with their peers throughout their daily routines.

Daily flash meetings and team meetings were held, these included a range of staff and topics to support the operation and running of the service, staff well-being and feedback. Recent staff surveys included information from the registered manager and about the action they took to address the feedback from the staff team.

The did not always have clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

There was evidence of audits being undertaken regularly. However, not all of the records we reviewed included confirmation that actions had been taken as a result of these or signed as reviewed by the management team. A detailed action plan was in progress and reviewed by the registered manager and senior team. A copy of this was being sent to the Care Quality Commission to provide updates on the progress of improvements. Up to date business and contingency plans were in place that would support the service in the event of an emergency event.

Information was being stored safely in the service and electronic devices had logins and passwords to ensure information was being stored securely.

There was evidence of a range of quality checks taking place, including visits by the senior team and night check visits by the management team. These records demonstrated checks on safety and security, tour of the service, documentation, people who used the service, staff, follow up from the findings of the last visit and a summary of the findings by the registered manager. The registered manager told us how they considered sustainability. They had developed an environmental sustainability plan which included, energy efficiency, water conservation, green transportation, waste management and an eco-friendly environment.

Staff understood their roles and responsibilities. The management structure was in place with support for the registered manager as required. However, not all governance tasks were completed when the registered manager was off. We discussed with the registered manager the importance of providing support to the clinical lead team in updating and reviewing care records. The registered manager provided evidence of the actions they took to ensure staff supported the senior team with updating people’s records.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Relatives confirmed that staff linked in with professionals, where this was required. Most professionals told us the service engaged and involved them in people’s care. One said, “I have visited the home a few times. The staff are lovely, the [Clinical lead] has also kept me informed throughout.” Records we reviewed confirmed professionals were involved.

The staff and the management team told us a range of professionals were involved in people’s care and support. We saw professionals visiting the service.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The registered manager and senior team discussed the range of improvements they had completed since the last inspection. An ongoing action plan was in place and amendments were being made as these were completed or further areas for improvement were seen.

Staff said improvements were ongoing since our last inspection. One told us they had, “Seen lots of changes since the last inspection. The home is a lot cleaner now and staff get on much better. We work as a team now.” A range of information and guidance was available and training was ongoing to support the staff team in their roles.

Records of incidents and accidents included information about lessons learned and lessons learned as a result of incidents and safeguarding was discussed as part of team meetings. Statutory notification were being submitted as required to the Care Quality Commission.