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

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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. The service was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment and the service was no longer in breach of this regulation.

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. Staff received regular supervisions where they discussed the organisational values, and monthly team meetings to share information and learning. A staff member told us, “We have team meetings every month, they are very helpful.” This helped the service meet its own aims and objectives as set out in its Statement of Purpose, ‘To enable individuals we support to live in a home which they can call their own and where they will be assisted and supported to lead a full and active life as valued members of the community.’

The service had inclusive leaders 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. Since the last inspection, a new manager was in post, and had made an application to become registered with the CQC. We received positive feedback about the new manager, who was visible and led the staff team by example. There was wider support for the manager from the provider through visits and management meetings. A staff member told us, “I feel very lucky to support the individuals at Maple House, as every day brings an opportunity to make a positive difference in their lives.” And, “[Manager] is fair and honest, which creates a positive environment where I feel valued and confident in my role.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The manager had introduced a staff suggestion box, so feedback could be given confidentially by staff if needed. The manager told us, “Every staff member is treated the same. I have a very open-door policy. Staff are made very aware of the importance of staff culture. I take any staff feedback seriously, and I follow through with this.” A Duty of Candour policy was in place, setting out the need for people to receive an apology when things go wrong, and for any adverse events to be investigated in an open and transparent way. Staff were confident any concerns would be acted upon by leaders, but also understood their own accountability to escalate issues externally if required. A staff member said, “I also know it is my responsibility to ensure concerns are followed up properly and not being ignored.”

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. Staff received training in equality, diversity and inclusion, and told us they felt valued. The manager told us, “I’m very proud of our staff. I believe each and every one of them works very hard and has the individuals’ best interests in mind in everything they do.” A staff member told us, “I've always been able to voice ideas to my manager. [Manager] has always listened and considered everything I've asked or requested. [Manager] has always respected my views and opinions and made me feel like a valued member of staff.”

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 service was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment and the service was no longer in breach of this regulation. The service completed a variety of regular audits in areas including health and safety and infection prevention and control, which all fed into an overall service improvement plan. This meant any actions were addressed and reviewed by leaders. Policies and procedures were in place to support the running of the service, but could benefit from some enhancement and review. For example, we identified some documents, including the business continuity plan, needed to be updated to reflect the change in management. The manager told us they would act on this feedback.

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. We saw the service carried out regular quality assurance satisfaction surveys with people and their relatives to check they were happy with the safety and quality of the care. The service had also worked in partnership with the local authority, including the quality improvement team, and with an external consultant to drive continuous improvement. A relative said, “I am very happy, staff are good, and things have improved.”

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 had invested in new electronic systems, which were being used to good effect and benefitting people living at the service. The Operations Manager told us, “Everything is a lot more technical, [manager] is really good when you come to technology, and all the [electronic care planning]. We have gone down the road of electronic medication records which kicks in in 2 weeks’ time. Technology is the big change here.” The provider had also invested in an external consultant to carry out mock inspections, with action plans created as a result.