Maple House Rehabilitation Unit

Updated 17 June 2026

We assessed Maple House Rehabilitation Unit from 21 to 22 April 2026, with additional online interviews completed on 29 April 2026.

Maple House was registered with CQC in 2016 to deliver the regulated activities: Assessment or medical treatment for persons detained under the Mental Health Act 1983 and Treatment of disease, disorder or injury. The service had a Registered Manager.

We visited the following wards as part of the inspection:

Elm ward, a high dependency ward for men with 10 beds

Oak ward, a high dependency ward for men with 9 beds

Maple ward, a high dependency ward for men with 9 beds

At this assessment we identified a breach of regulation 12: safe care and treatment and a breach of regulation 9: person-centred care.

At this assessment we assessed 1 assessment service group; Long stay or rehabilitation mental health wards for working age adults where we assessed 33 quality statements.

We rated the service as Requires Improvement. At Maple House Rehabilitation Unit, we found 1 breach of regulation in relation to safe care and treatment. During the previous inspection it was identified that the service should ensure that physical health monitoring, such as National Early Warning Score 2 (NEWS2), was recorded and followed up in accordance with national guidelines. During this inspection we found that there was no improvement and there was still a lack of consistency in the NEWS2 monitoring.

We found 1 breach of regulation in relation to patient-centred care. In the records we reviewed the patient voice was not present in care planning or risk assessments, patients did not feel involved in setting goals and there was limited evidence of goal setting or discharge planning.

We have asked the provider for an action plan in response to the concerns found at this assessment.

Updated 8 December 2025

The date of the assessment was 21 to 22 April 2026, with additional online interviews completed on 29 April 2026.

Maple House Rehabilitation Unit is an independent long stay or rehabilitation mental health wards for working age adults. The service was made up of three wards, Maple ward which had 6 beds, Elm ward which had 10 beds, and Oak ward which had 6 beds, the service only admitted male patients. During our inspection we toured the environments of each ward, attended handover, attended a group psychology education session, reviewed prescription charts and care records, spoke with 8 patients, 4 carers and 9 staff members including the deputy manager who was covering for the registered manager during the inspection. We gave verbal feedback which we confirmed in a letter to the provider shortly after our inspection.

We previously inspected Maple House Rehabilitation Unit in January 2024. We rated safe, caring, responsive and well led as good, and effective as requires improvement. Our overall rating of the service was good. At this inspection we rated caring, responsive and well led as good, and effective and safe as requires improvement. Our overall rating of the service was requires improvement.

We found breaches of the regulations in relation to safe care and treatment. During the previous inspection it was identified that the service should ensure that physical health monitoring, such as National Early Warning Score 2 (NEWS2), was recorded and followed up in accordance with national guidelines. During this inspection we found that there was no improvement and there was still a lack of consistency in the NEWS2 monitoring.

We also found breaches of the regulations in relation to person-centred care. In the records we reviewed the patient voice was not present in care planning or risk assessments, patients did not feel involved in setting goals and there was limited evidence of goal setting or discharge planning.

However, there was good engagement with activities, there were a lot of activities to support physical health and rehabilitation, as well as psychoeducation sessions. Staff had a good understanding of patients and engaged well with them.

The service reviewed serious incidents, highlighted learning, and implemented this effectively. Learning was also clearly shared with staff, and they used micro-learning in handover to reinforce and support learning. Ligature risk assessments were clear and comprehensive, which was an improvement from the previous inspection. Staff spoke positively about the service and culture, and there was a ‘Shout Out Friday’ to highlight achievements of staff and patients.

Mental Health Act

The service admitted patients under the Mental Health Act 1983. Staff received training on the Mental Health Act as part of their mandatory training, the current compliance rate was 85%.

The provider had relevant policies and procedures that reflected the most recent guidance, and staff could access administrative support and legal advice on implementing the Mental Health Act and its Code of Practice.

Staff explained to each patient their rights under the Mental Health Act and repeated this as necessary, this was recorded in a separate document overseen by the provider’s Mental Health Act administrator, who highlighted to staff when rights were due to be read. Staff ensured that patients were able to take Section 17 leave (permission for patients to leave hospital) when this had been granted. Patients confirmed they were able to take their Section 17 leave when they requested this. T2/T3 treatment forms (the legal authorisation for patients’ medical treatment under the Mental Health Act) were uploaded to the electronic prescribing system.

Quarterly audits were completed by reviewing a sample of files, and all files were reviewed as part of an annual audit.

Mental Capacity Act

Staff received and kept up to date with training in the Mental Capacity Act and had a good understanding of the five principles. Staff training on the Mental Capacity Act and Deprivation of Liberty Safeguards was mandatory and the compliance rate was 88%.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regards to significant decisions, and staff recognised the importance of a person’s wishes, culture and history. Staff knew where to get advice from within the provider regarding the Mental Capacity Act, including Deprivation of Liberty Safeguards.