Maple Lodge

Inspectors found enough staff to meet people's current needs and found that recruitment checks had been completed before staff were appointed.

“There were sufficient numbers of staff available to support people safely and meet their current care and support needs.” from the report

People could access health professionals, and staff worked with several services to support people's health. Hospital passports were also in place.

“People had access to health professionals when required.” from the report

People were supported with nutrition and hydration. Staff involved people in meals where they wished, and menus were discussed weekly.

“Service users and staff met weekly to discuss the menu and their preferences for the week.” from the report

People could see family and receive visitors without restrictions.

“People were able to visit family and receive visitors without restrictions in line with best practice guidance.” from the report

Untrained staff used physical restraint on two occasions. The incidents were not reported to the safeguarding authority or CQC, so they were not fully investigated or shared.

“The provider failed to respond or follow up the use of unauthorised physical restraint by untrained staff which had occurred on two occasions” from the report

Inspectors found limited fire marshal cover, too few recorded fire drills and no personal emergency evacuation plans in the emergency grab box. The plans did not properly reflect people's needs, including night-time staffing.

“There were no Personal Emergency Evacuation Plans (PEEP) held within the service's emergency grab box.” from the report

Some bathrooms, furniture, carpets and kitchen areas were damaged, soiled or difficult to clean. Inspectors said this created an infection prevention and control risk.

“These issues all created an infection prevention and control risk to service users as the environment was poorly maintained and unclean.” from the report

A PRN medicine used during distress was given 12 times in one period, but only one behaviour record was completed. Some staff also assessed each other's medicine competence without the required trainer training.

“In total staff had administered this medicine on 12 occasions during this period. We found only 1 behaviour record was completed” from the report

Not all staff had current practical training in restraint, moving and handling, first aid or fire safety. Training on learning disabilities and autism was also incomplete or out of date for some staff.

“The provider failed to ensure staff had up to date training to provide safe care and support to people.” from the report

The provider's checks did not identify the problems found by inspectors. Actions from meetings and requests for training were not consistently followed up.

“The providers governance arrangements were not reliable or effective.” from the report