Mapleford Nursing home

The following is CQC's published account of its assessment, published 2 September 2025. References to “we” mean CQC. It describes findings at that time.

This comprehensive assessment was undertaken between 24 June and 10 July 2025. We assessed all quality statements under the five key questions of Safe, Effective, Caring, Responsive and Well Led. The assessment was undertaken to follow up the last assessment where warning notices and requirement notices were served. The service is registered to provide accommodation for persons who require nursing and personal care for up to 54 older people, younger adults, people with a physical disability, sensory impairment or mental health support needs and people living with a dementia.

The last rating was requires improvement overall and requires improvement in the key questions of safe, effective and well led and good in effective and responsive. We identified breaches of regulations in relation to person-centred care, safe care and treatment, premises and equipment and fit and proper persons employed. We also identified a breach in relation to good governance of this service. We served warning notice in relation to good governance and asked the provider for an action plan in response to the other concerns found at the last inspection.

The provider had acted on the concerns identified at the last assessment. At this assessment we found improvements had been made but further improvements were still required in relation to medicines and managing individual risks

People were safe and incidents and accidents were investigated, managed and evidence of lessons learned was seen. Staff had undertaken safeguarding training but not all could describe what they would do to act on safeguarding concerns.

Records demonstrated the involvement of professionals and professionals told us they visited the service. We saw professionals visiting during our site visits.

The environment was clean and tidy and personal protective equipment (PPE) was available, not all daily cleaning checks had been done. Servicing and checks were taking place but not all had actions recorded of the findings and what was done. The registered manager told us what they were doing to address the findings from a recent fire safety assessment. Refurbishments in the service were ongoing with some improvements noted in the environment. Some individual risk assessments were seen. The registered manager provided information about what they were doing to ensure all of the electronic records contained up to date information about people’s individual risks.

Staff were recruited safely and had undertaken training. Specific training to support people with challenging behaviour was planned for all of the staff team. The registered manager told us there were recruiting more staff for various roles.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Care records contained some individualised information and were person centred however, these were sometimes difficult to follow. Daily records were completed and handover records contained information to support staff in delivering care to people. Staff told us they had access to information to support providing care to people and this was updated as people’s needs changed. Capacity assessments had been completed and Deprivation of Liberty Safeguards (DoLS) applications had been submitted to the assessing authority, these were being followed up by the management team.

People were offered choices of meals and there was evidence that professionals had been involved in assessing needs. However, not all people was provided with a meal in line with their requirements.

Professionals were positive about the service and the engagement and support staff offered. However, one discussed a concern about the support staff provided them at a previous visit. Professionals were involved and supported people.

Staff were positive about the management and the support they provided. Staff supervisions were taking place and team meetings were being held.

Information and guidance was on display and available to support the delivery of care to people. Systems were in place to record and act on complaints and concerns. Positive feedback was seen in surveys and questionnaires.

Information, training and guidance was available to staff to help support people’s end of life care and choice. Do not attempt cardio pulmonary resuscitation (DNCAPR) decisions had been recorded.

Staff were positive about the management and the improvements in the service. Information policy and guidance was available. Team meetings were taking place and regular news letters were available with information, updates and good news stories included.

Staff were positive about the registered manager and the support they provided, team meetings and night checks were taking place along with senior management team meetings that included evidence to support and drive improvements. Audits and governance checks were ongoing, not all of the audits included the actions taken as a result of the findings. Contingency plans were in place that provided guidance on how to manage in the event of an emergency in the service. An environmental sustainability plan had been developed to support reductions of the impact of the service on the environment.