Maple House Rehabilitation Unit

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs. At our previous inspection we rated this key question as good. At this inspection the rating has remained as good. This meant people’s needs were met through good organisation and delivery. Patients had access to education, volunteer and work opportunities, and staff supported them accessing these opportunities. The service ensured external bodies were notified when required. Information was given in a range of formats and languages, and additional information was available on notice boards throughout the wards. There was a clear complaints process through which learning and themes were identified.

However, the service did not always evidence how patients’ views and wishes were being considered regarding their care and treatment. There was also limited evidence of planning for the future, particularly the lack of clear discharge pathways.

We have not awarded this service a score for Responsive.

Find out about when we will not publish a key question score and what we look at when we assess Responsive.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Most people that we spoke with did not feel involved in their care and treatment and felt that their individual needs and preferences were not considered by staff. For example, many of the activities offered to patients where physical, so if a client had reduced mobility, the options to engage were limited. However, in the 12 months preceding our inspection, an audit had been completed which identified a need for a better range of groups and art and psychoeducation had been introduced as activities that did not require as much mobility.

Patients also raised concerns that there had been a change in the self-catering programme which meant patients would be given vouchers to shop with. This meant that their choice of shops was reduced. This was discussed with management who confirmed the decision was a safeguarding matter to ensure the budget was used appropriately, and they were reviewing this to improve the patients’ choice.

Each patient had their own bedroom, with an ensuite bathroom. They all had access to keys to lock their bedrooms to ensure that their items could be kept secure.

Patients were able to attend MDT meetings when this was clinically appropriate, and had access to advocacy for support. When patients were assessed as clinically ready, they attended specialist appointments such as dentist and hospital appointments independently.

We scored the service as 3. The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

Where appropriate, staff ensured that patients had access to education and work opportunities. Patients were supported to access education from local colleges, and staff supported patients who were considering accessing courses. Some patients had volunteer roles for charities, and when a patient preferred to access paid work they were supported to do this. For example, some patients were looking to apply for work as delivery drivers, and another patient had a job as a cleaner. One patient was also looking to learn to drive, and the management team were reviewing options on how this could be achieved.

Staff supported patients to maintain contact with their families, carers and friends. Where appropriate, patients were able to visit home, including overnight stays. Relatives and friends could also visit the service, there was a dedicated visitors room, and patients spoke positively of staff facilitating this. However, feedback from carers suggested that they sometimes had difficulty contacting the service to arrange visits.

Patients were supported to access their chosen place of worship in the community, and staff could provide examples of when patients had been supported to attend important services at their church. The service provider also had suitable materials and space to support worship within the unit, as well as an arrangement with a local care home, where patients could attend a non-denominational service at that location.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service made notifications to external bodies as required. Between June 2025 and February 2026, the service made 19 safeguarding referrals, which were shared in line with the services safeguarding processes. The service also made notifications to CQC and the police as required.

The service had an Accessible Information Standard policy which they complied with and when required the service could provide easy read, large print and braille documents. Interpreting services including British Sign Language could be accessed to support patients’ understanding when English was not their first language. Leaflets and documents could also be translated to support patients’ and their family’s comprehension.

At the time of the inspection, the service did not have a patient orientation booklet, but were co-producing one with social workers, with the aim for the booklet to reflect similar information an individual might be provided following discharge. The service also had information on notice boards in the wards which signposted patients on how to complain, raise concerns and compliments with CQC, information on care and treatments, their rights and blanket restrictions.

Patients’ carers, families and commissioners were invited to attend MDT meetings, and most carers we spoke with felt they were kept informed about their relative.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Between January 2025 and March 2026, the service received 44 complaints, 6 out of 44 were upheld, and no complaints were referred to the ombudsman. The service reviewed complaints for themes and trends, and where possible took action to resolve them. Key themes for complaints were catering, social worker allocation delays, disagreements with care and treatment, and staff related complaints. Actions taken included reviewing catering provisions and ensuring the MDT followed up with social care once a referral had been made.

Patients knew how to complain or raise concerns; however, some patients we spoke with were not always happy with the resolution of the complaint. The service had a process for handling complaints, with clear timelines, including 3 days to acknowledge and 28 days to provide a response, individuals would be updated if a response would take longer. The service’s office administrator supported the process, providing acknowledgment and arranging a formal discussion with the individual, which would be documented, and advocates invited to support. Staff received feedback on the outcome of investigations of complaints

The service had also received 29 compliments between January 2025 and March 2026, which included staff being helpful and supportive, and positive feedback from family members regarding care and treatment. The service had also introduced ‘Shout Out Fridays’ which promoted weekly positive feedback on achievements and expressions of thanks across the service, for both staff and patients.

We scored the service as 2. The evidence showed some shortfalls. The service
did not always make sure that people could access the care, support and treatment
they needed when they needed it.

The service had three wards across three floors, and there was a lift available for patients to move between floors when their mobility was reduced, however some patients expressed frustration at being on higher floors when they had mobility issues. Staff were able to make reasonable adjustments for patients such as accessing mobility aids, or supportive chairs.

In the last 12 months there were 4 delayed discharges, 1 each on Elm and Maple and 2 on Oak. These discharges were not delayed due to clinical reasons, but were affected by local system and funding pressures, the requirement of bespoke packages and limited availability for suitable placements. The delayed discharges disproportionately affected the average length of stay in the service.

In the care records that we reviewed, discharge planning for patients was limited, and although liaison with care coordinators and social workers was good, the service could only refer a patient to the local authority for discharge once the person was clinically ready, which reduced the possibility of proactive planning.

There was adequate medical cover day and night, with an assigned doctor on call across the provider and the service was within a reasonable travelling distance to the local acute hospital.

We scored the service as 3. The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff received training in equality, diversity, inclusion and human rights, and the compliance rate at the time of our inspection was 93%. Staff we spoke with were aware of how patients may be discriminated against in relation to protected characteristics under the Equality Act.

The service promoted a culture in which people felt empowered to give their views. The wards had regular community meetings, which allowed patients the opportunity to raise concerns or give feedback to staff in a formal process. Patients also had access to an advocate who regularly attended the ward and MDT meetings and were able to support patients in giving their views or raising concerns. Where possible, the service made changes to address what people raised.

The provider was conscious of ensuring that vulnerable people or people with protected characteristics were not placed at a disadvantage, and advocated for patients when it was appropriate, such as discharge planning with local authorities and commissioners.

We scored the service as 2. The evidence showed some shortfalls. People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

In the care records that we reviewed, there was limited evidence of advanced discharge planning, for example, across Maple and Oak only 2 out of 6 records showed a clear discharge plan in place. Patients we spoke with did not feel informed or involved in any discharge planning.

Care plans were not written in a way that ensured the patient’s voice was present, so it was not always clear that plans had been created to account for their needs, wishes and feelings.

However, staff ensured all relevant healthcare professionals and other relevant bodies were involved in planning the care and treatment of people with complex needs.