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.

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.

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 deputy manager shared with us the changes that had taken place since the last inspection. They told us, “It feels much better than at the last inspection. I feel much more supported. A clinical lead has been recruited and they are working well. The atmosphere here feels different. Staff seem to be a bit more positive.”

The regional operations manager told us, “We are developing a better culture. We now have more consistency in terms of nursing staff. We encourage a no blame culture when things go wrong. We are trying to teach, nurture and train.”

Changes had been made to the structure of the organisation, which better supported the deputy manager and clinical lead in decision making. The changes also reflected the variety and complexity of people’s needs in relation to their mental health and ensured more specialised support was available for the management team.

Staff spoke positively about the changes made. One staff member said, “I feel as though I could easily speak to any staff without any concerns when things go wrong. [Senior staff] will speak with you and say what needs to be done, but it’s about safety at the end of the day.”

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.

People and relatives spoke positively about the management of the home. One relative commented, “The home is lovely and does have good ratio of staff on duty. We feel as a family that this home does meet [person’s] needs and we are happy with the care provided.”

Staff were also positive about leaders within the home. One staff member said, “Very good management team, I am very happy to work here. You can make suggestions; we work well as a team, especially with our nurses.”

The deputy manager had a good understanding of their regulatory responsibilities and had notified The Care Quality Commission (CQC) of incidents and events as required. They, and the senior management team, were receptive to feedback provided as part of this inspection.

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 and felt confident to raise and escalate concerns. One staff member said, “I would raise concerns if I was worried about anything straight away. With [deputy manager], the nurse or team leader. I have no concerns that someone would act and investigate.”

The provider had processes in place to support people, relatives, and staff to raise concerns or share ideas.

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 spoke positively about the support they received and felt they were treated well. One staff member said, “I think the management team, especially the deputy manager is very good. They treat all staff well. It’s a lovely place to work.”

Staff had undertaken training in relation to equality and diversity and their knowledge and understanding of people’s individual diverse needs were evident when they spoke about the people they supported.

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.

Systems had been developed and established to drive the necessary improvements since the last inspection. Regular checks were carried out on the environment, equipment, incidents and events and medicines. The deputy manager and clinical lead undertook a range of audits to monitor the quality of care provided and reviewed the experiences of people living at the home. Completed audits were then used to create action plans, which detailed where changes or improvements were needed to improve quality and safety.

We found audits used to review the quality of recruitment practices had not always identified that gaps in employment histories were not always fully explained in staff files. The provider responded proactively to this feedback and implemented additional checks and processes to be carried out in relation to staff recruitment files.

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.

The management, nursing and staff teams worked in partnership with local agencies to ensure people’s health and wellbeing needs were met. Nursing staff made appropriate referrals when people’s needs changed and followed professional guidance to deliver safe and effective support.

The nursing staff maintained open communication between people, professionals and relatives. This helped to ensure people’s needs were understood and met in a timely way.

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 deputy manager and senior management team had established processes which promoted a positive culture around learning and improvement. The deputy manager shared how they had learned from their previous inspection and demonstrated how they had used the findings from the last inspection to improve the service and people’s experience of care.

The deputy manager and senior management team analysed records relating to incidents and events to reduce the risk of recurrence, as well as identify any themes or learning which could improve the quality of care provided to people.