Maplebrook Care Home

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.

This is the first assessment for this service. This key question has been rated requires improvement: This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of regulation 17 relating to good governance.

This service scored 54 (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 did not have a clear shared culture which was based on equity, equality and human rights, inclusion, and engagement. They did not always understand the challenges and the needs of people.

We found people were not provided with regular opportunities in which they could raise matters with leaders, for example, within resident meetings or via people satisfaction surveys. Staff meetings had not been taking place on a regular basis, which could have been used by the provider to promote and reinforce a clear and shared culture. This meant the provider did not always understood the challenges and needs of people, nor that they had a clear shared culture which was based on equity, equality and human rights, inclusion, and engagement.

There was a complaints and equality and diversity policy in place, staff had received training in these areas and neither people nor staff informed us they did not feel comfortable sharing their views with leaders should they have concerns, with relatives also saying that staff kept them updated with changes with their relation’s needs.
 

Leaders did not always demonstrate the skills and knowledge to lead aspects of the service effectively.

Leaders had mostly failed to identify and / or effectively address the concerns we have detailed within other sections of our report. For example, they failed to ensure incidents were managed effectively, safe staffing levels were in place and care plans provided accurate individualised information. This meant the service was not always managed effectively which meant there was an increased risk to people living at the service.

People felt they could speak-up and their voice would be heard.

The provider told us staff were aware of the importance of and process for raising concerns, and this is discussed with them within their supervisions.

While there was no information within staff meetings about how staff could raise concerns, the staff we spoke with did not tell us they had any issues in raising concerns.Similarly, although people were not provided with regular opportunities where they could raise concerns should they wish to, people mostly informed us they were happy with their care, and they would raise concerns with senior staff or the manager should they ever have any.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for the people who worked for them.

The provider informed us they valued a diverse workforce which they treated fairly. Staff supported this by telling us they were happy working with the provider and felt they were treated fairly. There were processes in place to consider staff member’s individual needs, such as supervisions.

Effective governance systems were not in place to ensure safety and quality concerns were identified and effectively acted upon.

Risks at the service had not always been identified and effectively acted upon to promote safety. For example, we found effective systems were not in place to monitor and improve documentation. We also found there was a lack of analysis of accidents and incidents. Governance systems in place failed to address shortfalls in staffing numbers and training. Systems did not consistently ensure care was provided promptly to people and in accordance with their identified needs. Systems failed to ensure risks associated with people’s needs were identified, acted upon and documented. The providers internal systems failed to identify and address issues relating to medicines management and the importance of social stimulation for people which we found during this inspection.

All of these concerns meant governance systems were not effective and exposed people to the risk of harm.
 

The provider understood their duty to collaborate and work in partnership in order that services could support people. While the registerer manager was aware of what partners and stakeholders were available to the service and how to access this support. We found people were not often supported to integrate within the wider community to improve their social and emotional outcomes. External healthcare professionals were not always accessed in situations where this could have improved people’s health outcomes.

The provider did not focus on continuous learning and improvement across the service.

Leaders did not always have a good awareness and understanding of audit processes and how these can be used to effectively identify concerns and mitigate risks to achieve continuous learning and improvement.

As a result, leaders had mostly not identified and effectively acted upon areas of the service which required improvement, such as those we identified during our inspection. This meant there were missed opportunities to learn and make improvements to the overall quality and safety of the service.