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 good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted 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 had a clear vision and culture, this was initially developed in 2019 with the ‘Promoting a positive culture’ document. This provided a clear description of what culture is, the providers values, what high quality care is and what is expected from staff. This was discussed at staff meetings and what this looks like in the service.

Staff understood the provider’s vision and what was expected of them to fulfil this. Staff told us they felt supported to provide good quality support.

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. Staff told us they were supported in all aspects of their role. They felt it was important that the management team were always available and were happy to support people when needed. The registered manager told us, “The deputy manager and me are supporting (Name) at a hospital appointment. They may find it all a bit overwhelming and by 2 of us going we can remove them from the appointment if needed, leaving the other to advocate for them in appointment.”

The operations director had previously managed the service and knew people and staff well. Staff had found this useful when identifying changes in people’s needs and requiring additional support.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were supported to express their views including ‘Speak up’ champions who reported back to the provider. Supervision and support had been provided to the champions, to enable them to complete their role effectively.

Staff told us they were confident to raise concerns, and action would be taken by the management team. Relatives told us they knew how to raise concerns. They found the staff and management team responsive to their concerns.

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. The provider had a policy in place to support equality and diversity in the workplace. During the recruitment process checks were completed to ensure staff could work in the country.

Staff had received an induction which included training and working with more experienced staff and having the competency checked. Staff told us, they had been made to feel welcome and included in the service.

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. There were effective systems in place to monitor the quality of the service including regular checks and audits. The management team completed checks and when shortfalls were found, action was taken to rectify them. The management team held a ‘Team safety huddle’ following an incident. These were also held when shortfalls had been identified to make sure there was a structure to any action taken and lessons were learnt. Staff attended governance meetings to discuss people’s support and their needs.

The provider had oversight of the service, the operations director attended the service regularly. They met with the management team and staff to discuss any concerns and provide support.

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. Staff were proactive in working with other professionals to make sure people received the support they needed. Staff had worked with the primary care network nurse to make sure people received the appointments and investigations they needed.

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. There was a learning culture within the service, staff told us they wanted to learn to improve the lives of people.

There was evidence the management team had recognised learning needs and accessed the required training for staff. The provider supported the management team to improve and expand their skills and knowledge, by supporting them to complete qualifications to support their roles.