Maple House Rehabilitation Unit

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our previous inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. There were shortfalls in the environment, in the clinic room there were gaps in cleaning records and expired items, and the patients’ views were not always considered in care planning to reduce risks. We also found that there was a lack of consistency in physical health monitoring, which we found at the previous inspection.

However, the service had a proactive and positive learning culture and had safe and effective staffing.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

In the last 12 months, the service had 3 serious incidents. Following these incidents a full review was completed to identify areas of learning at both the wider service level and for individuals. Examples of improvements to the wider service included the introduction of new hospital mobile phones, which staff used for completing observations, after issues were identified with the previous devices’ reliability and battery life. Due to lessons learned from another incident a new process for allocations and staff rotation across day and night shifts was introduced, this helped to improve governance and oversight, as well as reducing silo working and the risk of closed cultures developing. On an individual level, actions following incidents included mandatory refresher training, increased awareness on specific topics such as financial safeguarding, and reinforcing the expectations of staff when responding to incidents such as timely reporting and accurate documentation.

The service completed duty of candour when required, 3 incidents had occurred in the 12 months prior to inspection, and patients and representatives were given full and prompt explanations. Learning had also been identified from the incidents, which meant MDT actions were reviewed weekly for any potential changes to medication and section 17 leave.

Learning from incidents were shared with staff through bulletins, supervision, and ‘micro-learning’ sessions during handover. The micro-learning sessions were part of the regular handover agenda, which were used to highlight and reinforce areas of recent learning, or new processes that were being introduced to the service.

Staff we spoke with were able to identify what incidents to report, and they understood how to report them. Staff also told us they could get support from managers when reporting an incident. Staff understood the importance of the duty of candour, after incidents patients would have a debrief with staff, where they discussed their wellbeing, what happened, why and what could have been done differently. Patients told us they had received debriefs following incidents.

We scored the service as 3. The evidence showed a good standard. The service 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.

The service had an admission policy in place which established the inclusion and exclusion criteria for admission into the service. This included assuring that a patient’s needs could be safely met through assessment by at least 2 senior clinicians or mangers from at least 2 disciplines of the multi-disciplinary team (MDT). All patients had a pre-admission assessment, which would be carried out by 2 members of staff, including a senior member of the clinical team.

The service had a pre-admission report template to complete for each potential admission, which also included relevant histories, risks, and a handover from the individual’s current clinical team to support continuity of safe care.

Social workers or care managers had an expectation to maintain contact with the service and patient, attending MDT meetings to support continuity of care. Managers told us that the engagement from external teams was good, there were no issues with communication, and they regularly attended MDT meetings for their patients. When a patient was considered clinically ready for discharge, a referral would be made to a social worker to support discharge into safe housing that was appropriate for their needs.

Similarly, patients and their relatives or advocates were consulted were possible as part of pre-admission and then invited to attend MDT meetings during the patient’s period of admission.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding, and the current completion rate was 89%. Staff that we spoke with knew how to make a safeguarding alert and could access support from senior staff if required. The service had a safeguarding policy in place which defined abuse, and supported staff to identify potential indicators of different types of abuse, including physical, psychological, and financial as well as criminal exploitation and coercive control. The policy contained a checklist to support staff making a safeguarding referral to ensure that immediate risks were addressed, and relevant information was gathered to ensure a referral was appropriate. The service had local safeguarding leads, which were on posters around the unit, as well as regional leads from the provider.

Staff worked in partnership with other agencies, including local authorities and the police. Where relevant the service also liaised with additional external teams such as MOSOVO (Management of Sexual Offenders and Violent Offenders), and SOMU (Sex Offender Management Unit) to ensure appropriate support was in place to ensure the safety of patients and others.

The service had a blanket restriction register in place, which clearly identified the reason for each restriction to be in place, related policies and codes of practices, and how each item was reviewed. Where possible, risks were reviewed to be stepped down to individualised risk management plans, when this was not possible a rationale was included in the risk register. The service also had a poster available to help patients and visitors understand blanket restrictions and their role in safeguarding patients.

88% of staff had completed training in the Mental Capacity Act and Deprivation of Liberty Safeguards.

There were no Deprivation of Liberty Safeguard applications made in the last 12 months. The service had a policy on the Mental Capacity Act, including Deprivation of Liberty Safeguards. The policy established roles and responsibilities, who should assess capacity, and what should be covered in a best interest meeting. Staff were aware of the policy and had access to it. Staff we spoke with had a good understanding of the Mental Capacity Act and most knew where they could access support if required, however, newer staff were unsure.

Staff were aware of when a patient may have impaired capacity and could give examples of how the assessment was on a decision-specific basis, with certain actions taken to ensure the patient’s safety and wellbeing. Where these decisions had been made, there were ongoing reviews through MDT meetings. Any assessment was made on an individual basis, considering their best interests, while recognising the person’s wishes, culture and history.

We scored the service as 1. The evidence showed significant shortfalls. The
service did not work well with people to understand and manage risks. They did not
provide care to meet people’s needs that was safe, supportive and enabled people
to do the things that mattered to them.

During the inspection we reviewed 11 patient records. At 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 a lack of consistency in the NEWS2 monitoring. For example, in care plans it was recommended that monitoring should be completed once a week but the gaps between monitoring suggested reviews were happening more frequently or there were gaps between recommended monitoring without recording if staff had offered a review and the patient had declined. Following our inspection visit the provider submitted evidence that there was a system in place to monitor whether patients had declined, however these were not clearly recorded in the observation record. This meant the service could not be assured whether monitoring had been missed or declined. This was a breach of regulation 12: safe care and treatment.

Staff told us that they involved patients in care planning and risk assessments, as this was part of the admission process, and patients were invited to MDT meetings. Where appropriate, staff involved patients in reducing their own observation levels, contributing to care planning and risk assessments. However, when we reviewed the patient’s records, the patient voice was not present, and it was difficult to evidence where patient’s views had been considered. We also found that risk assessments did not feed into the care plan, which meant a risk might be identified in one document, but was not clearly identifiable in the other.

The service had moved onto an electronic care record system in the last 12 months, and they were still developing the system to better reflect the requirements of the service.

Patients that we spoke with felt that staff did not always communicate effectively to ensure that they understood their care and treatment. Patients told us they did not have a copy of their plan; we raised this with staff who confirmed they could request a copy of their care plan but said plans were not routinely given to patients. Managers confirmed that they could access easy read versions and a copy in another language if required to support patients’ communication needs. Patients spoke positively about their access to advocacy, and staff confirmed advocates regularly attended MDT meetings.

In the last 12 months there were 23 incidents of restraint, and 1 incident of rapid tranquilisation in the service. There were no incidents of prone restraint in the last 12 months. Of the 23 incidents of restraint, 19 related to 1 patient who had a complex presentation of behaviours, who had a clear care plan in place. Restrictive interventions were documented in patient’s care plans, and were regularly reviewed by the MDT, to ensure they were safe and appropriate.

We scored the service as 3. The evidence showed a good standard. The service
detected and controlled potential risks in the care environment. They made sure
equipment, facilities and technology supported the delivery of safe care.

The 3 clinic rooms had the required equipment, and staff were able to evidence they were calibrated monthly. Maple and Oak shared an emergency bag which staff were aware of, and Elm had its own emergency bag. The bags were regularly checked and had all required equipment.

Regular risk assessments of the care environment were completed, ligature risk assessments had last been completed in March 2026, high risk areas were appropriately highlighted, identified risks were fed into the regional risk register, and additional guidance was available. Potential ligature anchor points were clearly identified, and appropriate mitigations had been identified by staff. This was an improvement since the previous inspection.

The service had introduced a security booklet, which was completed in the morning by a nurse and the day’s designated security individual. A complete walkaround of the unit and outside area would be conducted to highlight any areas of risk, which included the environment, infection prevention and control measures and maintenance issues. Identified areas would be logged as assigned actions in the booklet. At the time of the inspection, this had just been introduced to the service, a trial version of the booklet had been completed, and during the handover we observed that the security lead completed a ‘micro learning’ session on the booklet. The service confirmed that the security booklet had increased awareness of maintenance issues, and timeliness of response.

The layout of the ward did not allow staff to observe all parts of the ward, however at the time of our inspection the service were in the process of installing CCTV cameras throughout the unit. The service provided a map of the CCTV camera locations through the unit, which would reduce the risk of blind spots in communal areas and corridors. The service identified blind spots directly underneath the cameras; to reduce the risk, some cameras had 360° movement. During the installation, a fire and ligature risk assessment had been completed, with risk controls in place as mitigation.

Patients had call buttons in their bedrooms, during the inspection we tested one of these alarms. When pressed the alarm sounded, and a light appeared above the patient’s bedroom to highlight the alarm had been pressed. All staff wore personal alarms.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The multidisciplinary team for Maple House Rehabilitation Unit had a range of disciplines including, nursing, support workers, clinical psychology, psychiatry, a physical health lead, and occupational therapy. These roles were also supported by Mental Health Act administration, a training manager, maintenance and administration. The service also had a physical health practitioner who attended the site once a week and directed any physical health referrals a patient may require.

The service had one vacancy of a whole time equivalent occupational therapist (OT), recruitment was currently underway for this post, and in the interim, a full-time OT apprentice was on site to provide occupational therapy who was supported and supervised by an OT from one of the provider’s other locations. This ensured there was still no gap in occupational therapy provision during the recruitment process.

The provider monitored sickness rates across the service, from January 2025 to March 2026 sickness absence was 14%. The service reviewed when there were high levels of absence, and for any themes around high acuity or increased risk and absence of patients. The average turnover of staff in the service was 23% across 12 months, the service monitored reasons for leaving.

Between May 2025 to April 2026, 91 shifts were covered by agency staff for support worker roles, during this timeframe, there service did not operate below the minimum safe staffing levels. Managers were able to deploy agency staff when staffing shortfalls required this, which was not often. The service had specific agency staff who would usually attend the unit, so they were familiar with the environment and expectations of the service, for new agency staff there was an induction checklist to support introduction to the unit. The agency staff also had core training provided by their agency.

Staff that we spoke with felt that staffing levels were appropriate. Managers ensured that there was always enough staff to carry out physical interventions, by ensuring that there were always 6 restraint trained individuals in the unit, while providing activities and escorted leave. In the day staff establishment was 2 nurses and 8-10 support workers, and at night it was 2 nurses and 7-8 support workers. During the 12 months before inspection the service had not operated below minimum staffing levels.

However, patients and carers told us that they felt staffing could be improved, staff were often busy and could not always support patients quickly, or their time on escorted leave was reduced.

The service had a training manager who was able to deliver or source training and monitored compliance. Most clinical training was outsourced to external companies, but some clinical training for induction was provided by the unit’s staff with the support of the training manager such as NEWS2 or learning disabilities and autism training.

Staff had received and were up to date with appropriate mandatory training, the service’s training target was 85%. The overall compliance rate was 88%, with high compliance in Oliver McGowan training (nationally recommended training on meeting the needs of people with a learning disability and autistic people), basic life support and safeguarding. Nursing and medical staff also completed intermediate life support which was at 87%. However, medicines management was currently at 65%, as compliance had been impacted by a new starter to the nursing team. The service confirmed that the induction process ensured full training compliance within 12 weeks, and this course was soon to be completed.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The unit, including all wards and patient accessible areas, was clean and unobstructed. There were areas around the unit that required some minor maintenance such as repainting, but all damage had been made safe by the provider. On Maple and Oak wards there were good furnishings that were well maintained, however on Elm a couch in the communal lounge had tears in it, managers confirmed that they were aware of this, and it had been logged in the maintenance actions log. The newly introduced security booklet included a review of IPC (infection, prevention and control) across the unit, and areas of concern could be highlighted for escalation and logged as an action.

We observed domestic staff cleaning the ward areas thoroughly through the morning, and the cleaning records were fully completed, up to date and demonstrated regular cleaning.

The unit completed regular audits on the environment, including environmental cleanliness, deep cleaning and mattress audits which were completed on a monthly basis. The service also had a monthly cleaning log. These audits were reviewed in the monthly IPC meeting, as well as Hospital Governance meetings. Actions from audits were regularly identified, such as general gaps in cleaning, identifying when infectious outbreaks would need to be reported, and identifying better ways to support patients’ involvement with cleaning. In response to some of the actions from audits, the service had increased their domestic staff by one whole time post.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Each of the 3 wards had its own clinic room, the rooms were small but suitable for dispensing medicines, the rooms were clean and tidy, however there were significant gaps in the cleaning records on Maple and Oak. In February 2026 there were 10 gaps, in March 2026 there were 20 gaps, and in April up to 22 April 2026 there were 7 gaps in the cleaning audit, which meant we were not assured regular cleaning of the clinic rooms was being completed.

There were also gaps in the temperature monitoring for the medicines fridge and clinic room, some temperatures were recorded on paper and other on the electronic system. This meant it was not clear which system staff should be using, and it was difficult to cross reference if temperature checks had been completed on a given day.

In the clinic rooms, clinical waste bins and sharps boxes had not been correctly labelled with the opened dates or signatures. We also found expired items in the clinic rooms, including topical and liquid medicines, dressings and sterile wash.

Controlled drugs were safely locked away.

During the inspection we reviewed 12 prescription charts and 11 care records. The service had processes and systems in place to ensure medicines were prescribed and administered safely; records were on an electronic system that were reviewed and audited by a third-party pharmacy service. Patients with high dose antipsychotic medication had the required monitoring in place. The service had a policy regarding the management of controlled drugs and the self-administration of medication.

Nursing staff received training in medicine management; however, the completion rate was at 65%, below the service’s target of 85% due to new starters in the team. New starters to the staff team were expected to complete all basic training within 12 weeks of starting.