Maple Cottage

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 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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider was in continued breach of the legal regulations in relation to good governance.

This service scored 36 (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 demonstrate a clear shared vision, strategy and culture which placed people’s experience of care at the centre of the service. People had not experienced consistently positive, person-centred care.

At the time of the inspection, there had been recent changes in the management and staffing structure due to safeguarding concerns around the culture and leadership of the service. However, we found the provider had previously missed opportunities to identify and address these concerns. The Nominated Individual had completed regular visits to the service. However, their audits did not record any concerns with the culture of the service or with people’s experience of care. The provider had failed to identify the risk of a closed culture developing in the service.

People and those important to them did not feel the provider engaged with them effectively to discuss how to improve the care people received. At the time of the inspection, the provider had not sent questionnaires or requested feedback from people and their relatives to ensure they were involved in shaping the direction of the service.

The provider had not always ensured there were inclusive leaders at all levels who embodied the right values to lead the service appropriately. During the inspection we identified a number of concerns with the management oversight of the service and this had impacted on the quality and safety of people’s care. The provider was not able to demonstrate they had effectively monitored management practices within the service to ensure leaders had the appropriate skills, knowledge, experience and credibility to lead effectively. For example, where the Nominated Individual’s audits of the service had identified gaps in the management checks, they had not requested any evidence of completion or followed up on outstanding actions. This meant they had failed to ensure these shortfalls were addressed.

At the time of the inspection, the provider had recently implemented changes in the management structure in the service. The interim management team were open in their communication with CQC and demonstrated a commitment to addressing the concerns identified.

Staff did not always feel they could speak up and that their voice would be heard. Whilst policies were in place to provide guidance about whistleblowing, we received mixed feedback about how well staff felt the Nominated Individual and management team listened to them and responded to issues when raised. This meant staff did not always feel their voices were heard.

The provider had relevant policies and procedures in place to promote equity in their recruitment and development opportunities. However, we received mixed feedback about how well the provider listened to the individual experiences and challenges of staff to ensure a flexible, fair and inclusive workplace.

The provider did not have effective governance processes in place. The provider had failed to robustly assess, monitor and improve the quality and safety of the service. At the last inspection, we identified concerns with the provider’s governance systems. At this inspection, we found continued concerns with the provider’s governance and oversight.

During the inspection we identified multiple issues with the oversight of key areas of people’s care including person-centred care planning, risk and safety management, dignity and respect and capacity assessment processes.

The provider had not implemented clear responsibilities, roles and systems of accountability. We found management audits and checks were missing or not up to date and the provider had failed to promptly identify and address these shortfalls.

The provider’s model of care did not follow best practice guidance and leaders did not demonstrate a commitment to reducing restrictions and improving people’s quality of life.

The provider did not work in partnership with other health and social care professionals to ensure services worked seamlessly for people. They did not share information and learning with partners or collaborate for improvement. The provider had not consistently acted upon feedback from health professionals to drive improvements in the service. For example, they had not always responded to information requests to evidence how concerns were being addressed or completed the requested action plans in response to external audits of the service.

The provider did not work collaboratively with people, those important to them or staff to develop an approach which focused on delivering person-centred care and supporting people to achieve good outcomes. The provider did not routinely ask people, relatives or staff to give feedback or make suggestions on how to improve the service.

The provider did not demonstrate a commitment to continuous learning and improvement. The provider had failed to demonstrate how they were effectively evaluating and improving the quality and safety of the service. Following the last inspection, the provider completed an action plan to tell us how they would meet the breaches of regulation identified. However, at this inspection we identified continued breaches of regulation. This meant the improvement plans and governance processes implemented had failed to identify and address the shortfalls in the service.

The provider did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. Leaders were not able to evidence how they worked with people, relatives and staff to build a culture focused on enabling people to enjoy a full life.