Maple Manor

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The service was previously in breach of the legal regulation in relation to safe care and treatment. Improvements were found at this assessment and the service was no longer in breach of this regulation.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety and investigated and report safety events. However, although incidents and lessons learned were identified and discussed amongst staff, this did not consistently translate to changes which would embed good practice. For example, we saw a repeated trend for 1 person becoming upset in the community, and staff had forgotten an item used for distraction and to reduce anxiety on more than 1 occasion. We raised this with the registered manager for review. The team leader told us, “We hold staff meetings monthly to which the incidents do get brought up and discussed, the lessons learnt go into a folder and staff will read and sign it, and any questions will come to us.” This needed to be further embedded in practice, to show that positive changes consistently come from lessons learned.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. Staff acted to support people to access healthcare appointments, including routine checks and tests, by planning adjustments such as extra time and ways to provide reassurance. A staff member said, “With blood tests we book a double appointment. We will take things we know they (people) enjoy and calms them, just so they aren’t at a heightened point.” Staff also supported people so they could prepare for transitions without becoming anxious or distressed. A relative said, “[Person] needs a timetable because [person] gets upset about when they see us, so [staff] do a timetable about when [person] is seeing us, where [person] is going, and use the PECS symbols.” The Picture Exchange Communication System (PECS), is a method of communicating through pictures rather than verbal words.

The service worked with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. However, minor improvements were needed to ensure the service always shared concerns quickly and appropriately. Whilst the majority of safeguarding referrals had been made in a timely manner, we identified 1 incident which could meet the threshold for safeguarding enquiries which had not been raised with the local authority. This was because a staff member was less familiar with the person’s care plan and did not demonstrate a full understanding how to respond to the person’s needs when out in public. We raised this with the registered manager, who made a retrospective safeguarding referral straight away and provided additional supervision and support for the staff involved. The local authority quickly closed this referral, as appropriate action had been taken. People’s relatives were positive about safety at Maple Manor. A relative said, “[Person] is in safe hands.” Staff received training in how to recognize abuse and neglect, and a safeguarding policy was in place.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks were assessed in specific areas, such as managing money, eating and drinking, medicines and how to support people when expressing anxiety or distress. We identified 1 person’s care plan needed to be made clearer, to show what staff should do if they needed to physically restrain the person as a last resort in the community, in order to keep the person safe. The registered manager completed this during the inspection. Staff had practical face to face training in how to carry out physical restraint safely and for the least possible time, reducing restrictive practice. People had a Herbert Protocol in place, which is a document to assist emergency services in quickly identifying and locating the person should they go missing. This helped to keep people safe from the risk of harm.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. At the last inspection, we identified a breach of the legal regulation regarding safe care and treatment, as plans were not robust enough to prepare for emergencies such as a fire. At this inspection, we found sufficient improvements had been made in this area. Rotas showed there was always a designated fire warden on shift, and people had thorough personal emergency evacuation plans (PEEPs) in place. Checks and audits were completed in relevant health and safety areas, such as legionella, gas and electrical safety, and regular fire safety checks and drills. However, although the registered manager had identified some areas which required attention within the environment, the provider did not always respond in a timely way to ensure there were funds available for replacements and repairs. For example, our observations showed chairs in the dining room had degraded fabric and needed replacing, but funds had not been made available for this. We also saw there were recommended works to the home’s vehicle identified in July 2025, but no action had yet been taken at the time of our site visit to address this. The registered manager confirmed this had been booked in following our inspection.

The service did not always make sure there were enough qualified, skilled and experienced staff. However, they made sure staff received effective support, supervision and development. Staff worked together to provide safe care that met people’s individual needs. At the time of our inspection, the provider had moved staff around between sister services to support another location. This had the potential to impact on people living at Maple Manor. We saw the team leader work diligently to support newer staff to understand people’s needs, in order to mitigate this risk. We received some mixed feedback about staffing. A person’s relative told us, “There hasn’t been a change of manager and they’re familiar staff, and that’s what’s so brilliant.” However, another person’s relative shared with us how newer staff were not always familiar with people’s needs, telling us, “I think the handover needs to be a bit more comprehensive.” Recruitment carried out at Maple Manor was generally safe. However, we found 1 staff member had been employed by senior leaders at a sister service, where the recruitment process did not follow best practice. The registered manager had tried to address this and had retrospectively sought 1 person’s full employment history. However, we also identified potential concerns with the validity of references. The registered manager acted straight away to put a risk assessment in place, and told us a new staff transfer form was being introduced to support continuity if staff moved between homes. Staffing levels met people’s assessed needs, as each person was supported on a 1:1 basis, and staff received an induction, supervision and training relevant to their role.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. We reviewed the environment and found it to be clean and hygienic throughout. Records showed staff received training in food hygiene measures, and how to limit the spread of infection. Staff completed daily cleaning tasks within the home. A staff member told us, “In the morning after breakfast we always clean the kitchen first. We do cleaning of the toilets, the bathrooms, hoover the carpets. We always clean the rooms every day as well, and after dinner we do the same thing. Night staff also do a deep clean in the kitchen.” We saw some people were involved with household chores, including doing their own washing in the laundry room.

The service did not consistently make sure medicines and treatments were safe and met people’s needs, capacities and preferences. We found paper medication administration records (MARs) were only transcribed by 1 senior staff member, with no additional checks, which posed the risk of errors and inaccuracies. We also found processes for booking out medicines for people when visiting their relatives did not always follow national best practice guidance. Additionally, some administrative documents needed to be updated to confirm staff providing medication support, following changes to the staff team implemented by the provider. The registered manager responded promptly to our feedback and told us they would act on this straight away. There was no evidence of any impact on people. We checked the balance of medicines in stock and found they were accurate, with no unexplained gaps in MAR sheets, showing people received their medicines safely and as prescribed. Medicines were securely stored. There was evidence to show learning from medicines errors, to drive continuous improvement. A relative told us, “Medication is given properly and they’re (staff) very thorough on that, because we get a sheet to sign. The medication is calming [person], they say.” Protocols were in place, to show therapeutic strategies for reducing people’s anxiety before offering ‘as needed’ (PRN) medication, in line with the principles of STOMP (stopping over medication of people with a learning disability and autistic people). Medication profiles were in place, showing how and where people chose to take their medicines, supporting choice and control.