Mapleford Nursing 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 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm.

Accidents and incidents were not always reported and managed safely, and staff recruitment processes were not always robust. Not everyone felt there were safe staffing levels and the environment needed improving to ensure people’s safety.

Medicines were not always managed safely, and concerns were found in the infection prevention and control practices at this service.

People felt safe using this service and relatives praised the admission process.

The service was in breach of regulation in relation to people’s safe care and treatment, premises and equipment and fit and proper persons employed.

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 service did not always have a proactive and positive culture of safety, based on openness and honesty. Safety concerns were not always investigated, and incidents were not always managed safely. Staff told us they knew what action to take should someone have a fall. However, we found 1 incident whereby medical attention was not sought in a timely manner. Audits of accidents and incidents did not always identify what action had been taken when someone had repeated falls. It was not clear what services, if any, the person had been referred to. Lessons learnt logs were found to be robust and it was evident actions had been implemented following on from this.

People and their relatives told us they felt safe using this service. One relative said, “It took a while but [person using the service] has grown in confidence and that’s down to them knowing they’re safe.”

The service 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 were transferred to and from hospital safely with documents including a care needs summary and medicines list. Initial assessments were in place and care plans and risk assessments were implemented 24 hours following admission to the service. Staff told us they were informed of new admissions to the service via daily handovers and felt they were kept informed by the management team. One staff member said, “When new residents [people who used the service] come to the home we are informed by the team leader at handover, they tell us all the person’s needs, so we know how to look after them.”

Relatives told us the transition process for their loved ones moving into the service was made easy by the registered manager. One relative said, “I contacted Mapleford and made arrangement firstly for me to have a look around, spoke to the [registered manager] who was very helpful, and took [person using the service] there to have a look.”

The service mostly worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, concerns were not always shared with the appropriate professionals as we found 1 incident of alleged abuse that had not been reported to the local authority. Staff knowledge on Deprivation of Liberty Safeguards (DoLS) was poor and not all staff knew what this meant in practice or which people living at the service were subject to a DoLS.

People told us they felt safe, and relatives praised the staff and management team for keeping their loved ones safe. One relative said, “[Person using the service] had been in a previous home and it just didn’t feel right, they are much more settled here and we know they’re safe.” Staff knew what to do should abuse be suspected and felt confident in reporting concerns to the registered manager or other outside professionals, should they need to. We observed staff to be kind and patient during all interactions with people.

The service did not always work well with people to understand and manage risks. Cleaning chemicals were left unattended on cleaning trolleys, powder used to thicken fluids was found in an unlocked cupboard and Personal Protective Equipment (PPE) was found in bathrooms within people’s reach. This could pose as a choking risk to people. Risk assessments were in place to guide staff on what to do should someone have an incident of distressed behaviours; however, daily records did not always explain the full details of what had occurred which would indicate how to help reduce future risks. Relatives told us staff managed periods of distressed behaviours well and could see a significant improvement in their loved one’s mood since their admission to the service.

The service didn’t always make sure equipment, facilities and technology supported the delivery of safe care. An improvement plan was in place to ensure improvements were made; however, we did identify some concerns to the environment including damaged wardrobes, chairs and flooring that needed replacing. Other risks were identified including cleaning products left unattended several times throughout the visit to the service.

Doors were key coded and corridors and communal areas were well lit. Medication and laundry rooms were kept secure. We saw evidence of fire drills taking place to ensure staff knew what to do should a fire occur. All relevant health and safety checks were completed and a fire risk assessment was taking place on the day of the assessment.

Staff knew what action to take should a fire occur and said they had training in this area. Relatives told us the environment people lived in was safe but felt the décor needed modernising.

The service did not always make sure staff recruitment processes were robust. We found gaps in employment records which had not always been explored and not all staff had interview records for their current role. References were not always obtained from the staff members most recent employer and gaps were present in agency staff and permanent staff training records. Staff training was rectified during the assessment process. Not all staff were having a supervision in line with the service policy. We saw evidence of staff having Disclosure and Barring Service (DBS) checks. This provides information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The dependency tool appeared to reflect current staffing levels. However, most of the staff we spoke to felt there was not enough staff. One staff member said, “On a day-to-day basis there is not enough staff.” We witnessed staff present in communal areas and we witnessed many activities taking place. However, not all staff were engaging with people, and we found there were occasions where people were sat with no meaningful activity whilst staff looked around with no positive engagement.

Relatives praised the staff and found them to be caring and polite and although some concerns were raised in relation to staffing levels, relatives did say there were always staff present in communal areas.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Parts of the service required work to ensure effective infection prevention and control practices. The flooring in some parts of the home was sticky and unpleasant odours were present throughout the day. Wardrobes were damaged and skirting boards were dusty. PPE was stored alongside dirty laundry in communal bathrooms and laundry bags were stored on the floor in the laundry room. Although the kitchen appeared clean and tidy, we found food items stored in bins on the floor and various food items open but not dated or named. This meant we could not be assured how long the food had been opened and whether it was safe for consumption. Gaps in cleaning schedules meant we could not be assured cleaning tasks were taking place daily. Some of these concerns were identified in a recent infection control audit but had still not been rectified.

Staff had completed training in this area and an improvement plan was in place for decorative and maintenance works to take place.

The service did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Some medicine concerns found on the previous inspection had improved. However, there were areas of concerns that needed to improve to ensure people were receiving medicines correctly. Topical Medicine Administration Records (TMAR) were in place. However, the directions on the TMAR and the frequency of administration were not always in accordance with the prescribed instructions. This meant creams were not always applied correctly for 3 out of the 8 residents reviewed. We found 3 staff who administered medicines were not up to date with some of their mandatory training relating to medicines.

Two members of staff told us they did not have direct access to online policies and procedures and used a paper file to access policies and procedures. We found the medicine policy within the file had past it’s review date by over 12 months. When required protocols did not always guide staff on when and how they should be used. The dose prescribed by the person’s doctor did not always match what was written on the when required protocol, which increased the risk of errors. Records did not always explain distraction techniques used before a medicine was used for people who experience anxiety.