Maple House Rehabilitation Unit

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

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 previous inspection we rated this key question as good. At this inspection the rating has remained as good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. The service had a clear vision and values, and staff were aware of how these applied to their work. Leaders in the service were visible, open and had the skills and knowledge to ensure effective delivery of care. Governance processes operated effectively. Teams had access to the information they needed to provide safe and effective care and acted when learning and improvements were identified.

However, there was a lack of clear direction regarding the rehabilitation model of the service and there were no examples of innovation or research within the service. Some audits were also not robust, as we found regular gaps in clinic room cleaning audits, fridge temperature monitoring, and expired items in the clinical room.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were aware of the provider’s vision and values and understood how these applied to the service’s model of care, and this was introduced to staff as part of induction. Staff we spoke with felt that senior leaders were visible and created a positive culture that reflected the organisation’s vision and values. Staff had the opportunity to highlight where they felt the service might benefit from changes to better support the patients they cared for. This included changes to job roles and processes.

Staff were motivated and proud of the work they did in the service. Staff were knowledgeable about the needs of the patients, and advocated for them where possible, which reflected the values of the provider. However, there was a lack of clear direction regarding the rehabilitation model of the service, which was visible in the lack of discharge planning and rehabilitation goal setting within the service.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had a good understanding of the service they managed and the patients needs. They understood how each role worked to ensure high quality care was delivered by each individual and as an effective team. Leaders reflected and encouraged openness and integrity in the service, which meant that staff communicated with leaders when they had concerns or required additional support.

Staff told us that they had good relationships with senior members of the multi-disciplinary team, they were visible and accessible, and staff felt empowered to raise concerns. Patients we spoke with knew who the hospital managers were and had spoken to them when discussing their care and treatment or raising concerns.

There were opportunities in the service for leadership development, and staff within the service had moved through roles into leadership or roles with increased responsibility. The service’s training manager was also looking to source leadership training to support this.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The service conducted regular surveys for staff, patients and carers. The staff satisfaction surveys were undertaken twice a year; the last survey response rate was 80%. Where the responses highlighted a need for improvement, such as staff’s understanding of other roles, or staff wanting access to more opportunities to develop skills, managers responded by adding noticeboards that explained MDT disciplines and reviewing training opportunities.

Patients also had a twice-yearly survey, in addition to the regular community meetings throughout the year. To show their response a ‘you said, we did’ poster was completed showing the feedback from patients and the actions they had taken to respond. For example, the service was looking to roll out a patient portal in the coming year, so patients could access their care plans directly, and a blanket restrictions poster was shared to help understanding of the service’s restrictive interventions. The service also developed an action plan following responses from the family/friend/carer survey, which included reviewing communication with families to support leave and other contacts, and developing an admission pack to share ahead of admission.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider, Krinvest Limited, had a ‘Be You’ campaign to celebrate equality, diversity and inclusion throughout the organisation. The aim of the campaign was to encourage staff to complete the survey to better understand the diversity of the workforce, supporting staff to complete action plans on development, and championing equal chances for staff and patients.

When possible, staff were enabled to work flexibly in the service, to support people’s personal circumstances, such as caring responsibilities or breaks scheduled in a way that supported an individual’s health and wellbeing.

Maple House was also a level 1 Disability Confident employer, having completed the self-assessment and pledge, which is a government scheme to encourage employers to think differently and improve how disabled staff are recruited, retained and supported to develop.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes.

Staff completed regular clinical audits, which were reviewed as part of the governance agenda. Care records were completed monthly, which included risk assessments, activity data and incident reviews, additional audits included medication management, security and health and safety. When audits had highlighted areas for improvement, these had been implemented into the service. They included improving compliance for section 132 rights, and a review of groups that were available to patients. A daily nursing task sheet had been implemented to improve physical health observations, however, during our review of care records, we found that there were issues in the frequency of these observations.

Similarly, there had been minimal improvement in the gaps in cleaning audits, fridge temperature monitoring, and expired items in the clinical room. This suggests that the audits were not as robust as they could be.

However, the service had a clear framework in place with established governance domains which were reviewed at governance meetings, such as risk management, infection prevention control, clinical effectiveness and safeguarding. These were reflected in Maple House’s governance and team meeting agendas. This ensured that essential information was shared with staff, which included positive learning updates which highlighted physical security, service improvement and patient care. When learning was identified from reviews of incidents and complaints, managers ensured that recommendations were implemented to support service improvement, which included how referrals to social care teams were followed up and improved equipment.

Staff understood the arrangements for working with other teams, both within the provider and externally, to meet the needs of the patients. The service engaged regularly with commissioners, social services, local authority safeguarding and police. They worked together to identify service improvements and increased support for patients.

The service had a risk register, which covered all wards, and had severity ratings for each item, and mitigating actions. The risk register was regularly updated with the progress towards completion or ongoing mitigation. The identified risks included the environment, violence and aggression in the service, and access to dental practices. Staff at ward level felt empowered to escalate concerns when they identified them.

Staff had access to the equipment and information technology they needed to do their work, and when concerns were identified, action was taken to source equipment and improve support. For example, new staff phones for observations. The service and staff were aware of the importance of confidentiality, and this was identified as an ongoing risk to maintain awareness. All paper records were kept securely, and electronic records required a login, all staff had their own login, and there was a separate login available for agency staff to safely access patient records.

Team managers had access to information to support them in their management role, which included information on key performance indicators, staffing and patient care. Information was in an accessible format, and was timely, accurate and identified areas for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service engaged with external stakeholders including the local authority, police, commissioners and other community groups to support care, and ensure improvements could be made when concerns were identified. For example, following concerns with substance misuse around the service, Maple House took advice from police to reduce risk in the environment. Host commissioners also undertook regular audits and completed quality visits of the service.

The service was also working with social workers to develop a patient introduction and orientation booklet aimed at supporting understanding of concepts such as tenancy and independent living.

Patients and carers were invited to attend MDT discussions, as well as safeguarding processes and multi-agency discussions, where appropriate.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

The service was focused on ensuring rehabilitation was based in practical real-world skill development, promoting graded exposure and staged independence. This included variation in activities including community activities, CPR training, and patient safeguarding education, to develop transferable life skills.

The service had completed a peer review for Quality Network for Mental Health Rehabilitation Services, and other staff members had completed peer reviews for other sites. The aim of this was to recognise achievements and identify areas for improvement throughout the service.

Managers had also developed an action plan in line with CQC regulations, that aimed to identify areas where improvements could be made, ensuring better oversight through audits and governance processes.

However, there was limited involvement in national audits, or research initiatives within the service. Staff did not use quality improvement methods to establish how innovations taking place in the service had resulted in change or improvement.