Maple Lodge

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 inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was remained inconsistent. The service was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment and the service was no longer in breach of this regulation, However, the provider’s commitment to maintaining a robust and sustainable management structure across all their locations required improvement.

Robust systems had been established to effectively monitor and manage the quality of the service at Maple Lodge, encompassing safeguarding, auditing, medicines, staffing and staff training. The registered manager had demonstrated a strong commitment to learning from past challenges and had implemented a clear strategy for ongoing improvement and development at Maple Lodge.

This service scored 61 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, and an understanding of the challenges and the needs of people and their communities.

The provider operated several services in close proximity, which resulted in staff being deployed across different locations to meet operational needs. While this approach supported flexibility, it also placed additional demands on staff and management.The registered manager was also expected to support 2 other services nearby due to lack of management arrangements in place. We were not assured the provider had considered the organisational risk to the direction and culture of the service.

The registered manager and staff in Maple Lodge demonstrated the values and behaviour expected of them. They followed the principles of ‘Right support, right care, right culture’ guidance to ensure people with a learning disability and autistic people had respect, equality, dignity, choices, independence and good access to local communities most people take for granted. People were at the centre of life at the service, they were involved and engaged by staff to make choices and decisions.

Staff understood the challenges people faced and were committed to finding ways to overcome barriers to inclusion and participation. A staff member said, “There is a strong culture of teamwork and inclusion. Different opinions are welcomed, and we always work together to reach a common ground that is in the best interest of the people.”We observed during our assessment that the registered manager and staff demonstrated a positive and compassionate culture which promoted trust and understanding between them and people using the service.

The provider did not have 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. Whilst leaders had the skills, knowledge, experience and credibility to lead effectively, their skills were often used in multiple locations.

The registered manager had applied to become the registered manager at another of the provider’s services. Whilst they demonstrated the skill and ability to oversee another service, we were made aware they were also providing support to an additional location. This resulted in their expertise and leadership being stretched across multiple sites, which had an impact on the consistency of support available to people and staff.

There was a strong management structure in Maple Lodge with leaders who had the necessary skills and knowledge to lead effectively. The registered manager, supported by the deputy manager, led by example and were role models for the staff. A staff member said, “Communication within the team is open, supportive, and transparent. Staff morale is positive, and there is a strong sense of commitment to providing the best possible care. The culture is professional yet caring, which makes Maple Lodge a rewarding place to work.”

Leaders were compassionate and inclusive of working together with staff as a team. They were visible and available in the service. They were well thought of and known by the people, staff, family members and professionals. A family member told us, “[Name of registered manager] is lovely and you can see the relationship [name of relative] has with them.”

At the last assessment, incidents were found which had not been acted upon openly and transparently. Improvements had been made to this process, and the registered manager fully understood their responsibilities in relation to incident, accidents and safeguarding processes. A professional told us, “I've not been made aware of any recent information of concern about the service and [name of registered manager] has been proactive in the past at reaching out for any support as needed.”

At the last assessment, the registered manager had not addressed staff performance issues or was being provided with supervision by the provider. The process and procedures for supervision had improved. The registered manager completed supervisions with staff and where issues of performance were raised there was clear evidence these were being addressed or followed up.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.There was a culture of speaking up where staff actively raised their concerns and were supported, without fear of detriment. The registered manager was open to feedback and staff felt supported to speak up and were confident their voices would be heard.

Team meetings and learning sessions were held to discuss the work at the service and staff had the opportunity to discuss their views and ideas. Staff received supervision meetings with the registered manager which were clearly recorded to show progress and appreciation of their work. A staff member told us, “There is freedom to speak up about any issues or concerns without fear.” Another staff member said, “Communication within the team is open, supportive, and transparent.”

The provider valued diversity in their workforce. However, they did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had further work to undertake in promoting workforce equality across its services. Staff reported that whilst they had a consistent staff team at Maple Lodge, they could be asked to support the provider’s other locations as required, which occasionally disrupted continuity within teams.

Staff members’ protected characteristics were considered to ensure their rights under the Equality Act 2010 did not have a negative impact on their wellbeing. A staff member told us, “I was integrated quickly with no discrimination. I feel staff at Maple Lodge are treated with respect and fairness.” Staff had undertaken training in equality and diversity to support wider awareness in their role and responsibilities.

A process was in place to act on staff feedback and to promote fairness amongst the staff team. The registered manager commented, “Staff have communicated how they see a difference in the service, how well the team support one another and how the individuals they support have overcome barriers they never thought possible. Staff now reflect on their practice, how to better themselves and this has created a positive environment with happier people they support.”

The provider did not always demonstrate clear responsibilities, defined roles, and robust systems of accountability to ensure effective governance. Governance and management arrangements at Maple Lodge had been improved since the last assessment. However, the consistency of staffing and oversight of Maple Lodge depended on the long-term sustainability of all the providers locations.

At the previous assessment, governance arrangements were ineffective, and oversight of risk management, safeguarding, and staff training was lacking. Since then, the registered manager had taken decisive action to address these issues. They had implemented systems and processes to strengthen oversight of governance, staffing, and safety across the service.

Staff now had clearly defined roles, including key worker responsibilities and champion roles for fire safety, first aid, medicines, sensory needs, health and safety, and infection prevention. Staff had received training for these roles. A safeguarding ethos was visible throughout the service, including on notice boards, providing clear guidance to staff, people using the service, and visitors.

Support plans, risk assessments and best interest decisions were up to date and stored electronically, enabling staff to access and update records efficiently. These plans were person-centred and monitored through the key worker system, with oversight from the registered manager. As a result, people experienced improved outcomes and greater involvement in their care.

Health and safety training had improved, including training on Legionnaires disease, fire evacuation drills, and personal emergency evacuation plans (PEEPs). These measures ensured risks were identified and mitigated. Staff confirmed they received regular supervision and annual appraisals, which supported their professional development and competency.

Quality audits were detailed and current, providing assurance that risks were managed and improvements sustained. The registered manager maintained regular contact with other managers and the provider, contributing to monthly reports and attending managers’ meetings. Formal supervision of the registered manager had improved but was inconsistent and did not always support the registered managers workload and responsibilities.

The registered manager understood their responsibility under duty of candour to be open and honest and investigate when things went wrong. Sustaining new systems and processes would need to be monitored effectively to ensure they were well maintained and met the developing needs of the service. The registered manager was clear on their legal and regulatory requirements and made notifications to the local authority and CQC where appropriate and in a timely way.

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 registered manager and staff partnered with key agencies to deliver better outcomes for people. For example, they made timely referrals and sought advice when people’s needs changed, demonstrating a joined-up approach to care delivery. We observed good practice that reflected ongoing relationships with key health professionals, including the GP, occupational therapist, optician, dentist, and chiropodist.

People accessed local resources, and staff proactively sourced social and leisure activities that people enjoyed and wanted to attend. This approach increased people’s participation, involvement, and integration within their wider community.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Whilst overall Maple Lodge had significantly improved, more work was required by the provider to ensure consistency of management and staffing and deliver equality of outcomes for people and staff who used and worked for the service.

The registered manager and staff proactively and creatively delivered safe care and support. For example, an occupational therapist provided information and advice on using sensory objects to enhance communication, and an art therapist supported individuals experiencing loss and bereavement. Staff used accessible formats to ensure they met people’s preferred communication needs, enabling individuals to participate fully and make informed choices about all aspects of their lives.

Staff continuously sought ways to gather people’s views and preferences and helped them understand events that could affect them. For instance, they researched easy-read and pictorial guidance for testicular cancer checks. They also sourced accessible materials to explain hospital procedures, which positively impacted people’s experiences.

Staff consistently measured outcomes and evaluated the impact of care, treatment, and support on individuals and the overall development of the service. They recorded monthly reviews in a newsletter format, including photos of people engaging in activities, health updates, and changes to their care. Staff incorporated these newsletters into support plans and shared them with family members to keep them informed and involved.