This inspection took place on 25 and 28 September 2018 and was unannounced. Maples Care Home is a ‘care home’. People in care homes receive accommodation and nursing, or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Maples Care home is set over three floors and provides nursing and personal care and support for up to 75 older people. At the time of our inspection, 71 people were using the service.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection on 11 October 2017, improvements were needed to the range and frequency of activities provided by the home. At this inspection we found that this was still an issue, as frequent activities were not being carried out.

At this inspection we found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There were breaches of legal requirement because analysis in relation to accidents and incidents was not fully carried out to look for patterns or trends to reduce these risks and learning was not disseminated to staff. There were no pictorial menus and written menus were not provided in a large font that people could read easily. The home’s electronic care planning system was not always effective because during our inspection, the home’s internet connection was frequently lost throughout the day. We found that care files did not have back up paper care plans and risk management plans for staff to refer to. The provider had systems in place to monitor the quality and safety of the home, however, these were not always robust nor effective because they had failed to identify and address the issues we found during this inspection. Areas of improvement identified in the annual relatives’ survey 2017 remained areas of improvement identified at this inspection. They had not been rectified in a timely way. You can see what action we told the provider to take at the back of the full version of the report.

Improvements were also needed because we observed that people had to wait long periods of time for their lunch. There was limited staff interaction with people and staff seemed to be task focused. We observed that some staff were not always caring when communicating with people or assisting them.

People told us that they felt safe, and there were safeguarding procedures in place to protect people from the risk of abuse. Risks were assessed and identified and appropriate risk management plans were in place. Medicines were safely managed and people were protected from the risk of infection. There were enough staff deployed to meet people’s needs and the provider followed safe recruitment practices.

Staff completed an induction when they started work and were supported through a programme of regular training and supervisions to enable them to effectively carry out their roles. People's needs were assessed prior to moving into the home to ensure their needs could be met. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff told us they asked for people’s consent before offering them support. People were supported to have enough to eat and drink. People had access to healthcare professionals when required to maintain good health and the service worked with them to ensure people received the support they needed. The service met people's needs by suitable adaptation and design of the premises, with appropriately adapted bathrooms to manage people’

This unannounced inspection took place on 11and 12 October 2017. At our last inspection of the home on 24, 26 January and 01 February 2017 we had found some areas for improvement with the way ‘as required’ medicines were managed and some care records and some risk assessments were not always accurate. We found staff did not always receive regular supervision to support them in their roles and improvements were needed to the provision of suitable activities to stimulate people and meet their needs for socialisation. The new manager had already drawn up an action plan that had identified all the areas for improvement we found and had started work on completing this plan at the time of the inspection.

Maples Care Home is a large nursing home which provides long term residential care and support, nursing care, dementia care and respite services for up to 75 older people. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. There were three separate units at Maples, with separate facilities. Two of the units specialise in providing care to people living with dementia. At the time of our inspection there were 66 people living at the home.

At this inspection on 11 and 12 October 2017, we found improvements had been made to all the areas previously identified but there was still room for improvement with the range and frequency of the activities provided to ensure people’s individual needs were met. There were high levels of agency staff at this inspection and some people and some of their relatives told us this meant that their preferences and wishes in respect of their care were not always consistently met. However, the provider and registered manager had a robust induction for agency staff and had recruited a number of new staff who were due to start work in the near future. They told us they tried to use the same agency staff whenever possible.

There was a registered manager in place who had managed the home since October 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People told us they were safe and well looked after. Staff were aware of the possible signs of abuse and neglect and what to do if they had a concern. The registered manager had reported any safeguarding concerns and the local authority said the home had worked with them in an open and transparent way. Risks to people were identified and guidance in place to reduce the risk of them occurring. Risks in relation to equipment and the premises were assessed and managed and there were plans to deal with emergencies. Medicines were safely managed.

We received some mixed feedback about staffing levels. We found from our observations there were sufficient numbers of staff to meet people’s needs.

People told us staff were kind and caring. We saw people felt comfortable with staff and there was evidence of good relationships between most staff and people at the home. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice. People’s needs in relation to their disabilities, race, sexual orientation, religion and gender were recognised and supported appropriately. Staff told us they received sufficient training and support to know how to meet people’s needs.

People’s nutritional needs were met and a range of health professionals were available to support their health needs. People and their relatives told us they were treated with dignity and respect and that they were i

This unannounced inspection took place on 24 – 26 January and 01 February 2017. At the last comprehensive inspection on 27 and 28 January 2016 we had found a breach of legal requirements in relation to records. The provider had sent us an action plan to tell us how they were going to comply with legal requirements. We carried out a focused inspection on 24 June 2016 to check that the action plan had been completed and found that the service met legal requirements.

Maples Care Home is a large home which provides long term residential care and support, nursing care, dementia care and respite services for up to 75 older people.

Since the last inspection there had been some unavoidable changes in the management team at the home. The previous registered manager had left the home in July 2016. A new manager had been appointed and started work at the end of October 2016. They were in the process of registering as manager with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The deputy manager had also left and a new deputy manager had just started at the home.

We found there were some areas for improvement in some key questions as a result of the lack of stable management there had been. These included ensuring some care records and risk assessments were consistent and up to date, the recording of some best interest decisions and the provision of suitable activities to stimulate people and meet their needs for socialisation. Staff had received regular training but supervision had not always been provided to staff in line with the provider’s requirements. However, the new manager had already drawn up an action plan that had identified all the areas for improvement we found and had started work on completing this plan at the time of the inspection.

Medicines were stored and administered safely. We have made a recommendation to the provider about the safe management of ‘as required’ medicines and the arrangements for the administration of medicines covertly where this is appropriate.

People told us they felt safe and well looked after at the home. Staff were aware of how to raise any safeguarding issues. There were safe recruitment procedures in place. People and their relatives told us there were not enough staff at all times to meet people’s needs. During the days of our inspection however we found there were enough staff to meet people’s needs. The manager told us they felt problems arose when staff were not effectively deployed and they were working to address this issue. We will monitor progress with this at our next inspection.

People gave us mixed feedback about the food but said they had enough to eat and drink. Nutritional risk was monitored and plans were in place to reduce risk. People had access to a suitable range of health care professionals and staff made appropriate referrals when needed to meet people’s needs. Staff sought consent from people when offering them support. The service acted to comply with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), where people had been assessed as lacking capacity to make certain decisions about their care and treatment.

People told us they were well looked after and comfortable. People were involved in making decisions about their care and treatment. Staff knew people‘s preferences and respected people’s dignity. There was a calm atmosphere at the home. Relatives and visitors appeared relaxed and said they felt welcome. There was a complaints system readily available and responses had been made in line with the provider’s policy. Annual surveys and relatives and residents meetings were held to capture people’s experiences of care

We carried out an unannounced comprehensive inspection of this service on 27 and 28 January 2016. A breach of legal requirements was found in respect of records; accurate records had not always been maintained and there was therefore a risk of people not receiving the care they needed.

After the comprehensive inspection, the provider sent us an action plan to say what they would do to meet legal requirements in relation to this breach. We undertook this unannounced focused inspection on 24 June 2016 to check that they had followed their action plan and to confirm that they now met legal requirements.

At this focused inspection we looked at aspects of the key question ‘Is the service responsive?’ This report only covers our findings in relation to the focused inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Maples Care Home’ on our website at www.cqc.org.uk.

Maples Care Home is a large residential home which provides long term residential care and support, nursing care, dementia care and respite services for up to 75 people.

There was no registered manager in place. The current manager had been employed since February 2016 and was in the process of applying to become registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found that people’s care records were accurate and reflected their current needs and preferences to guide new and unfamiliar staff. There was a system to audit and check that care plans remained accurate and reflected any changes to people’s needs.

While improvements have been made and legal requirements are met, we have not been able to review the rating for this key question; to improve the rating to ‘Good.’ This was because at the previous inspection we found, although the provider met legal requirements, some improvements were needed in the provision of activities to meet people’s needs for stimulation and social interaction. We did not inspect this area at this inspection but we will review our rating for the key question ‘Is the service responsive?’ at the next comprehensive inspection.

This inspection took place on 27 and 28 January 2016 and was unannounced. At the last inspection on 26, 27 and 28 August 2015 we had found that while some improvements had been made from the inspection of April 2015 when the provider had been placed in special measures, there were still breaches of regulations. These were in respect of the safe management of medicines, and in identifying and monitoring risks to people. We took enforcement action following the inspection in August 2015 and imposed urgent conditions on the provider’s registration regarding the concerns we found in the management of medicines, and also imposed conditions on their registration in relation to issues we found in the management of risks to people. These conditions required them to submit regular information to us as to how they were addressing these concerns. We also served a further notice to limit any new admissions to the service, and served a warning notice in respect of a breach for not following procedures for safeguarding adults. The service continued to remain in special measures.

We carried out this inspection on 27 and 28 January 2016 in line with our special measures policy. We checked what progress had been made in respect of addressing the breaches identified at the August inspection and also carried out a comprehensive ratings inspection.

At this inspection the home was providing nursing or residential care and support to 37 people. There was a manager but no registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. There had been two changes of manager since the last inspection and the service had been managed by the provider’s Head of Operations on a temporary basis since the end of October 2015 while a new manager was recruited. A new permanent manager had been successfully recruited and was due to start in February 2016.

At this inspection we found considerable improvements had been made in each key question, although we identified a breach of regulations in respect of records of people’s care not always being up to date or accurate. You can see the action we have asked the provider to take at the back of the full version of the report.

There were some areas which required improvement. Staff awareness about how to evacuate people in an emergency was not consistent. ‘As required’ medicines guidance lacked detail to guide staff and pain relief assessments on one floor were not reviewed with appropriate frequency. People gave us mixed feedback about activities and relatives of two people told us they experienced some inconsistency with the way their preferences about their care were met.

People using the service said they felt safe and that staff treated them well. The warning notice we had served had been fully complied with. Safeguarding adult’s procedures were robust and staff understood how to safeguard the people they supported. People’s medicines were managed appropriately and they received them as prescribed by health care professionals. Risks to people were identified and monitored. There were enough staff to meet people’s needs and the provider conducted appropriate recruitment checks before staff started work.

Staff received adequate training and support to carry out their roles. They asked people for their consent before they provided care and demonstrated a clear understanding of the Mental Capacity Act 2005(MCA) and the Deprivation of Liberty Safeguards (DoLS).

People and their relatives, where appropriate, had been involved in planning for their care needs. Care plans and risk assessments provided clear information and guidance for staff on how to support people. People were supported to have a balanced diet.

Regular residents and relatives meetings were held where people were able to talk to the manager about the home and things that we

We considered our inspection findings to answer questions we always ask providers when we visit to inspect a service; is the service caring, responsive, safe, effective and well led.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with staff and from examining records. If you want to see the detailed evidence supporting our summary please read the full report.

At the time of our inspection there were thirty eight people living at the home. We looked at the personal care and treatment records of people who use the service, observed how people were being supported and the interactions they had with staff, talked with people who use the service and their family members and spoke with members of staff.

Is the service caring?

People expressed their views and were involved in making decisions about their care and treatment. People who use the service were given appropriate information and understood the care and support choices available to them. People using the service told us they were involved in the planning of their care and had been given choices about their support and how it was provided. One person told us, “I like living here. The staff are very patient and support me with anything I need." One visiting relative we spoke with told us “I am very much involved with my loved one’s care. The staff include me when decisions are made, reviews are conducted and when changes to the care plan is required." People we spoke with confirmed that their wishes and choices were respected by members of staff.

Staff members we spoke with were knowledgeable about people's health and social care needs and how best they can support people to meet their needs. We saw that staff were patient and responded promptly to people's requests for support. One member of staff we spoke with told us, "I'm very happy in my job and enjoy supporting people. We treat each person as an individual and always respect their wishes." Another member of staff said, “We have a keyworker system in place and this allows us to become familiar with people’s needs."

Is the service responsive?

We saw that people using the service were supported in a way that promoted their choice and independence. People’s care and support plans were made clear where people were able to manage their own care needs. For example, we saw records to show that one person was able to manage some of their personal care needs. Other support plans identified where people were able to choose their own clothes and arrange their own social activities. One person commented, “Staff know me well. They are aware of what I can do and how I like things to be done."

People using the service and visiting relatives told us they had visited the home before making a decision about whether they wanted to move in. One person told us, “I visited the home several times to see if it was suitable for my loved one. We are very happy with the care being given so far and I have absolutely no concerns about the staff or the home." We looked at a sample of peoples care plans and records. These confirmed that people's needs had been assessed prior to receiving support. Assessing and obtaining information about people's needs in advance supported staff to develop people’s care plans effectively. Care plans took account of people’s strengths, needs, abilities, likes and dislikes and the support they required to enhance their independence.

Is the service safe?

During our tour of the home we noted that many parts of the building were only accessible to staff members. The home used an electronic tag system which allowed members of staff access to all areas of the building. This system ensured the safety of people using the service by limiting access to stairs, lifts and doorways particularly on the dementia floor where some people were at risk of leaving the building. There were arrangements in place to deal with foreseeable emergencies. People using the service had a personal evacuation plan in place which measured the support people required in the event they needed to be evacuated from the premises.

The home had clear procedures on the safeguarding of vulnerable adults from the risk of abuse including how to recognise types of abuse and what action to take. The registered manager showed us the provider’s safeguarding adults from abuse policy and procedure and told us this was used in line with the "London Multi Agencies Procedures on Safeguarding Adults from Abuse." The registered manager also showed us the local authority’s procedure for reporting abuse and the contact information they had with details of who to contact within the local authority should they have any concerns.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. One application had been made and approved. People who use services are only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the Deprivation of Liberty Safeguards. Proper policies and procedures were in place to provide staff with guidance about legal requirements. Relevant staff have been trained to understand when an application should be made, and how to submit one .

Is the service effective?

We observed members of staff speaking with people using the service and their visiting relatives in a dignified and respectful manner. We observed that people's bedroom doors were closed when personal care was provided and saw that staff members knocked on people’s doors before entering. We observed that people using the service were well groomed and appropriately dressed. This demonstrated that people's dignity and privacy was maintained.

People were provided with a choice of suitable and nutritious food and drink. Some people using the service were able to make meal choices independently. Other people using the service required support from staff to choose their meals. We observed staff supported people to make choices from the menus that were displayed on each of the tables within the dining room. Where people were unable to make a choice, staff used their knowledge of people’s likes and dislikes to make decisions for them. People were provided with an alternative choice of meal if they did not like the day’s menu.

Is the service well-led?

Members of staff we spoke with confirmed that recruitment checks were made and that they had an induction period that consisted of training and shadowing other members of staff. Records we examined confirmed that induction training consisted of mandatory areas such as infection control, safeguarding vulnerable adults, Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS) and the management of medication.

The provider took account of complaints and comments to improve the service. We noted there were three complaints of a minor nature recorded in April 2014 which had been addressed promptly. We observed that the home’s complaint policy was displayed within the reception area of the home and people using the service had also been provided with a copy for reference.

We looked at the provider’s analysis report for the staff questionnaire that had been conducted in April 2014. Results showed that 81% of staff members were happy with the training provided and 75% of staff were happy with the way the home was being run. We spoke with the registered manager who told us that the home had developed a residents and relative’s questionnaire which they plan to conduct in August 2014. Residents and relatives meetings were held on a frequent basis at the home.

This inspection took place on 26, 27 and 28 August 2015 and was unannounced. Maples Care Home is a large residential and nursing home which provides nursing and residential care and support, dementia care and respite services for up to 75 older people. There were 41 people using the service during this inspection. There were three units in the home, one provided nursing care, another provided care for people living with dementia and a third unit that provided support and care for people with behaviour that requires a response.

There was a registered manager at the home but we understood they had left the home in September 2014 and had not yet deregistered as the manager. CQC is working with the provider to ensure this process is completed.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. There was a new manager at the home at this inspection, who was in the process of submitting an application to become the registered manager for the home.

At the last inspection on 7, 8 and 9 April 2015 we found multiple breaches of regulations and the home had been rated Inadequate overall and was placed in special measures. This meant we kept the service under review and planned to re-inspect within six months of the last inspection.

We took enforcement action in respect of staff training, arrangements for consent and protecting people and arrangements for infection control and issued three warning notices. We asked the provider to take action to make improvements in these areas by 31 July 2015. We also made requirement actions in respect of meeting people’s nutritional needs, showing dignity and respect to people, person centred care, complaints system and quality assurance processes. The provider sent us an action plan in respect of the breaches found and we carried out this inspection to ensure the warning notices had been met and action identified as required in other areas was progressing.

At this inspection on 26, 27 and 28 August 2015 we found there had been some improvements made in most key questions. There was a new manager at the service at the end of May 2015 and a new owner of the service from the beginning of July 2015. Some changes had been made; the provider had taken action to address the concerns in the three warning notices and some of the requirement actions made following the last inspection had been met. People and their relatives told us they felt some things were improving although they were unhappy with the rate of change. This provider is in special measures. This inspection found that there was not enough improvement to take the provider out of special measures.

CQC has taken further enforcement action and is now considering the appropriate regulatory response to resolve some of the problems we found. The key question Safe remains rated as Inadequate although the service is now rated overall as Requires Improvement. We will report on some of the action taken at a later date. We are closely monitoring the service and require the provider to submit information on a regular basis to assure us of the safe running of the service.

Risks to people were not always identified such as risks from medical conditions or risk to skin integrity. Medicines were not safely managed or administered. We have taken enforcement action in respect of these concerns and you can find the details of the action we have asked the provider to take at the back of the full version of this report. CQC is currently considering other appropriate regulatory responses to address the other breaches found at the inspection in respect of safe care and treatment. We will report on this at a later date.

While people told us they felt safe and some safeguarding alerts had been raised appropriately systems to identify and protect people from abuse or neglect were not consistently followed. You can see the action in respect of safeguarding adults we asked the provider to take at the back of the full version of this report.

There were safe recruitment processes in place and enough staff to meet people’s needs. Staff knew what to do in an emergency. The service was clean and there were adequate measures taken to reduce the risk of infection. Arrangements were in place to comply with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. These protect people who may not have the capacity to make some decision or may need their liberty restricting for their own safety. Staff received training the provider considered mandatory and regular supervision and told us they felt supported. People had access to health care professionals when needed and were protected from the risk of malnutrition and dehydration.

People told us they were involved in their care and that permanent staff were caring and kind but some night and agency staff less so. They told us they felt their privacy and dignity was respected and we observed this to be the case at the inspection. We found there was evidence of some good quality care and support but also observed instances of poor care.

People’s needs were not always identified in their care plans and there was not always guidance for staff to follow. People’s need for stimulation and interaction were not consistently met and we received mixed feedback about activities provided. The provider had recently recruited a new activities organiser and had plans to improve the quality of the activities on offer. People knew how to make a complaint.

People, their relatives and staff were complimentary about the new manager and said they were visible and approachable. However, they felt the pace of change was too slow. There was an absence of senior staff to support, lead and encourage improvements to be maintained. There were systems to monitor the quality of the service and drive improvements but these had not identified the issues we found. However the provider was in the processes of reviewing the quality assurance system although we were unable to judge the effectiveness of changes at this inspection.