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 inadequate. At this assessment the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. The governance processes at this service were not robust enough to identify concerns found at this assessment. Some of the concerns found were present at previous assessments meaning the service is not sustaining good processes and systems. Some staff felt there wasn’t a positive culture between team members, however, all staff praised the registered manager and felt there were positive changes at this service. Equal opportunities were available for all staff and staff felt the leaders of this service promoted good values. The service was in breach of legal regulation in relation to the governance of the service.

This service scored 57 (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. Policies and procedures were in place for equality and diversity and staff had training in this area. The registered manager told us that when they recruit new staff, they ensured inclusivity and welcomed staff from all backgrounds. The service’s values were shared with staff during their induction and at meetings to remind staff of the values of the service. The registered manager also told us the vision for the service was to promote a safe, loving and caring environment for all who work and live there. Staff praised the registered manager for making positive changes to the service. One staff member said, “They have good values here the (registered) manager. They always listen and I always feel safe working here.”

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. However, concerns were found in the governance processes at this service. A range of audits and quality checks were in place. However, they did not always identify the concerns found during the assessment process and a lack of oversight was evident in this area. Some of the concerns found were present during the last inspection process and improvements were still required to strengthen the governance systems of this service. We saw evidence of resident and staff meetings where various topics were discussed and information on lessons learnt was shared. Staff described the registered manager as approachable and felt they had good nursing and management skills. Staff felt supported by the registered manager and the nominated individual and said they were both present at the service.

Although there was evidence of an open culture at the service. Not all staff felt their voices were heard. Some staff felt there was not always a positive culture between team members and did not always feel listened to by each other. Staff however did feel able to approach the registered manager should they have any concerns. A whistleblowing policy was in place which offered guidance for staff on what to do should they have a concern.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. There were equal opportunities available for staff in relation to in house promotions and the registered manager told us the service employed a varied, diverse group of employees who all respected each other. Staff told us they felt the leaders of the service treated them fairly and that they promoted good values. One staff member said, “The (registered) manager is caring and good. They always listen to staff.” Staff had completed training in equality and diversity.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes. Although there appeared to be oversight of quality processes by the registered manager and the nominated individual, there were areas of concern which needed to be addressed. At the last inspection there were concerns around staff supervision and medicine management and these concerns were still present during this assessment. Medicine audits completed by the service failed to find the concerns found about topical medicines and when required protocols and supervisions were not occurring in line with the service’s own policy. The concerns found in staff recruitment evidenced a lack of oversight in this area and staff recording of incidents were lacking, meaning there was no clear analysis recorded of events that had occurred. Although audits were completed, they did not always identify the concerns found during the assessment. Many people had no toothbrushes in their bedrooms, despite an audit taking place highlighting the need for an oral care audit to be put in place. The provider was not always following their own policies and procedures and there was some confusion as to how staff accessed these policies.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborate for improvement. Care plans held evidence of partnership working and partners felt positive that this service engaged well with them. The registered manager told us they had access to peer support groups and a registered managers’ network support group to learn from other managers in the industry and enhance their knowledge. People and their relatives felt supported, and one relative praised the staff for assisting their loved one out into the community.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. Quality assurance systems were not robust enough to identify the concerns found during the assessment process and more robust systems needed to be implemented to ensure improvements were made at this service. Some of the concerns found at this assessment were present at the last inspection or the inspection before which evidenced a lack of sustainability for good practices. We did see evidence of information sharing between the registered manager and the nominated individual and lessons learnt was shared amongst the staff team.