Maple House

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

We looked at all quality statements for Well-led at this assessment. The service was not always Well-led. Whilst improvements had been made, further work was still needed to show governance systems were consistently effective. Feedback from system partners showed the management team had sought relevant feedback to develop the service and improve the quality and safety of care. This still needed to be developed and monitored to ensure sustainability. The provider was working on transforming the culture of the service, and there was improved visibility of the management team. Legal requirements were met, such as submission of statutory notifications to the CQC for events such as serious injuries, safeguarding matters or DoLS application outcomes. During our assessment of this key question, we found continued concerns about governance systems, which resulted in a breach of the legal regulations. You can find more details of our concerns in the evidence category findings below.

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 provider had recently developed company values with staff and people’s input. A staff member told us, “One of our company values is ‘achieve excellence’, and we try to do this every day.” This needed to be monitored and reviewed, to ensure effectiveness.

Staff had been supported to access external culture workshops to drive improvements in staff culture and speaking up. However, there was still further work required to ensure this was fully embedded and understood by all staff in practice.

At the last inspection, the registered manager also held director responsibilities at provider level and held the position of offering support to other sister services. This had now changed so the registered manager could focus solely on the running of Maple House, improving their oversight. There was enhanced support from the provider’s Nominated Individual. The registered manager told us, “[Provider] visits are more regular. There is more input.”

There were more provider visits, and regular management meetings across sister services to share learning. This process still required further development to show how the provider followed up on agreed actions and monitored them for effectiveness, so the same issues were not repeated.

Staff told us they felt able to share concerns with leaders and were confident this would be acted on. However, some incident records showed issues were not always identified in order to be highlighted for action. The provider told us they would act on our feedback.

Processes required further development to monitor and continue to embed a positive and open culture at the service. A duty of candour policy was in place.

Staff received training in equality and diversity, and regular team meetings took place to promote staff inclusion. The team leader told us, “We have implemented things like a suggestion box, staff meetings. We want staff feedback; we want to hear if staff have anything to say and it is all very open door.”

Some policies and processes to support workforce diversity and inclusion needed further development. For example, there was a lack of understanding at leadership level about the process for recruiting overseas workers.

At the last inspection we placed formal conditions on the provider’s registration with the CQC, requiring a weekly rota to be supplied to confirm staff training and a monthly action plan setting out improvements and safe practice relating to the use of physical restraint. The provider had complied with these conditions and submitted reports as required. Leaders expressed commitment to the continuous development and improvement of the service. However, the provider had not yet had time to demonstrate the improvements made would be embedded and built upon going forwards.

Whilst improvements had been made, systems to assess, monitor and improve the quality of the service had not yet been fully developed and embedded. Processes working well in some areas had not yet been extended to others, such as oversight of recruitment practice. Some areas for improvement had not been identified by the provider prior to our assessment, such as issues relating to recruitment and consistent use of positive language, although action was promptly taken or planned once raised. People’s information was not always securely stored, such as handover information on display above a staff desk based in people’s lounge area which could impact on privacy and confidentiality. The registered manager told us they would review this following our feedback.

People and those important to them felt more able to work in partnership with the service and be involved in their own care. A relative said, “We have a meeting, and they (management) take my views on board.” Another relative said, “I think it is well managed, since CQC has been in, it has opened their eyes, and it is dramatically different.”

Staff told us they experienced better partnership working, including amongst the staff team. A staff member told us, “The biggest improvement since the last inspection? Communicating better with each other.”

The provider understood their duty to share information with partners and collaborate for improvement. This included in relation to safeguarding matters, and statutory notifications were made to the CQC about this as required. A professional who works with the service said, “Organisational safeguards are in the process of closure, there are no ongoing concerns.”

Mechanisms were in place to support collaboration within the workplace, and more widely with system partners. This required further development to ensure consistency and continuous improvement and development.

Staff were committed to improving the services, but structures were still not fully formed to ensure any changes were consistently monitored for outcomes and impact. A staff member told inspectors, “We have all as a team put in a lot of work to improve and I hope you guys see the improvement we have made. And, if there is any more feedback, we can work on that as well.”

The provider had invested in an external consultant to support improvement works, which were ongoing at the time of our assessment. Work by the external consultant still needed to be embedded. A home improvement action plan was in place.