Maple Leaf Lodge

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 inspection we rated this key question requires improvement. At this the rating has changed to good. This meant the service was well managed and well-led. Leaders were working hard to improve the culture within the service to promote high-quality, person-centred care.

This service scored 75 (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 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. The provider’s statement of purpose said they aimed to; “To deliver a person - centred service in which dignity, privacy, right to choice and enabling independence of each service user ensuring these are maintained and all evidence is completed. Reflecting our commitment to person-centred care, to enable and actively encourage the participation of the people we support and those acting on their behalf, in decision-making about service planning and delivery.”

The provider 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. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. Where they had identified concerns, actions were taken and the registered manager was supported by the provider to improve the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. “Your voice” was a system of regular meetings with the registered manager used to enable people to have a voice in their care and as a result of these meetings changes to what people were doing through the day had already been made. Also people felt they were able to discuss any issues directly with the management team.

Staff felt supported to speak up, there were staff meetings and any information that needed to be communicated quickly was sent as a memo to all staff. The registered manager said there was an open door policy and staff felt they could raise any concerns directly with the management team.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. All staff had access to training around equality, diversity and human rights and we did not identify any signs to indicate a provider that did no value diversity in the workforce.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate. The provider had systems and processes to ensure there was clear oversight of the service and how it was performing. The registered manager carried out regular checks and audits and was quick to respond when issues or concerns were identified. There were clear aims and objectives the registered manager wanted to achieve, and these were aligned to the CQC principles of right care, right support and right culture.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Feedback from health professionals was positive and they felt the registered manager and staff worked with them to bring better outcomes for people. Initially when we spoke with relatives, concerns were raised they did not always feel involved in their loved one’s care. We raised this with the registered manager and when we returned, we found meetings with relatives had commenced and feedback and input was being promoted.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The provider used evidenced based practice in its approach to providing care. Systems and processes were constantly reviewed and developed in response to lessons learnt from across their range of services. The provider gave care and support to complex people and ensured that care was in line with the ethos and principles of enablement and maximising people’s potential.