Maple Manor

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 remained 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 previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment and the service was no longer in breach of this regulation.

This service scored 57 (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 vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The registered manager was committed to the running of Maple Manor. However, this service was 1 of 5 sister services in a cul-de-sac. The provider had asked the registered manager to also support 1 of the other services as well as Maple Manor. There had also been movement of staff to support the other service, with more experienced staff who were familiar with people’s needs moving out of Maple Manor. The provider had not demonstrated how they had considered the impact on time, resources and oversight at Maple Manor, and this did not reflect a shared direction and culture. This led to issues as identified in Safe, linked to staff being less familiar with people’s needs. The registered manager was aware of this, and was committed to addressing the situation going forwards, with a review planned after 3 months.

The provider did not always have inclusive leaders at all levels at who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. However, leaders within the service itself had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty. A relative told us, “I’ve no concerns at all because I can raise anything without worry. [Maple Manor] is extremely well run by [registered manager] and the way [registered manager] feeds through to the staff.” Another person’s relative said, “[Registered manager] and [team leader] are both amazing, are very practical, hands-on and use common sense.” The registered manager and team leader were visible in the home during our inspection. However, as the registered manager was also supporting another service at the provider’s request, this took management resources out of Maple Manor for periods of time. This had the potential to impact on oversight and leadership at Maple Manor.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were confident they could share any issues or concerns with the registered manager, and this would be acted on appropriately. There was a whistleblowing policy for staff, and a duty of candour policy which set out a commitment by the service to an open and transparent approach. People received an apology when things went wrong, using methods to aid effective communication such as easy read or social stories. Staff understood how to escalate any concerns outside the organisation if required, reducing the risk of a closed culture. A staff member told us, “I would report [any concerns] to my senior straight away. I would report to my senior staff, the manager, the company, safeguarding, CQC, or Colchester police.” Another staff member said, “[Leaders] would listen if I raised concerns, I have no problems in speaking to management. They do listen.”

The service 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 told us they felt valued and included. Despite this positive feedback, short notice changes to staffing made by the provider without adequate consultation meant this was not sustainable. This practice had the potential to impact on staff morale and feelings of inclusion. Records showed staff received formal equality, diversity and inclusion training. A staff member told us, “Anything I’m worried about I can knock on [registered manager’s] door, or if I’ve just had a thought, [registered manager] might say, ‘Oh good idea’, or ‘Try it this way’.”

The service had clear responsibilities, roles, systems of accountability and good governance at location level. 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. However, there were some challenges caused by decisions made at provider level, which had the potential to impact on the running of the service and the sustainability of improvement works made. The service was previously in breach of the legal regulation in relation to governance. Improvements were found at this assessment, and the service was no longer in breach of this regulation. At our last inspection, we found governance arrangements were not effective at provider level, and a lack of investment meant staff did not have key training necessary for their role. Since the last inspection, the provider had employed a consultant to support them to oversee the service, including supervisions for the registered manager. A range of quality assurance checks were in place. Regular management meetings were held, and the provider carried out visits to the service. Staff had received training as required. The registered manager had the skills, knowledge, and experience to perform their role and a clear understanding of people's needs, and the service ran effectively despite some continued weaknesses at provider level. This meant the potential impact on people was reduced. Systems and processes were in place to support effective oversight. Legal and regulatory requirements were met, such as submitting statutory notifications to the CQC about any injuries, allegations of abuse and DoLS application outcomes.

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. We saw the service had worked well with an external consultant to drive improvements at the service, as well as with other stakeholders in health and social care. For example, we received positive feedback from a healthcare professional who works with the service who told us there had been improvements at Maple Manor in recent times. The service also sought comments, suggestions and feedback from staff, professionals, people and their relatives about the quality of care provided, supporting a partnership approach. The registered manager told us, “We are proud of how active the residents (people) are here, we promote independence and have a great rapport with the families.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research. However, the service did encourage creative ways of delivering equality of experience, outcome and quality of life for people. At the last inspection, we found there was a lack of urgency by the provider to address recommendations and issues in a timely manner, including those raised by the registered manager. Although some areas were not promptly resolved, we saw evidence of continued investment by the provider, for example a new kitchen had just been installed at the time of our site visit. Recruitment carried out by senior leaders had not been completed correctly, showing lessons had not been learned from previous CQC inspections within the wider group. This placed pressure on the service to address weaknesses and gaps. Despite this, the registered manager was committed to continuous improvement, and had a dedicated home quality improvement plan, which clearly identified areas to address, drawing actions from a wide range of checks and audits. This supported a broader learning culture within the service itself, and showed the registered manager was alert to the needs and priorities of the service. People were supported to have a good quality of life, and staff supported them to have full and meaningful experiences.