Maple Court

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• 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

We identified a breach of legal regulations in relation to governance. Quality assurance systems had not been effective in consistently identifying areas for improvement and taking actions to address these. Elements of documentation required improvement to ensure they contained consistent and up-to-date information. Meetings were held to share information and updates. There was a whistleblowing policy and staff knew how to speak up.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We received mixed feedback from staff in relation to the leadership and the support they received. For example, some staff noted their limited contact with the management team particularly if they worked nights. However positive comments included, “My manager seems to listen to everything I have to say” and, “They are supportive of me. I can speak with the manager directly and the deputy. They are always on the floor with us. They are giving support all the time.” A staff member described the actions the registered manager had taken to support them during a difficult personal time.

There was a registered manager and deputy manager in post, who were supported by regular visits from the quality and regional management team. The management team understood their roles and responsibilities.

Staff told us they felt confident to whistle blow should they feel it necessary. The registered manager highlighted information displayed throughout the home to support staff. This included information about safeguarding, whistleblowing and how to raise concerns outside of the organisation.

A whistleblowing policy was in place to support staff. Staff were able to provide feedback about the home.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The governance processes used had not been effective in identifying issues for improvement. The registered manager understood their responsibilities. They noted visits were undertaken outside of usual office hours to observe the care provided to people. The registered manager was responsive to the feedback we gave and had started to take actions.

Governance systems had not always been effective in identifying issues and driving improvement. They did not identify some of the failings found during our assessment including concerns with medicines, risk management and elements of infection prevention and control practice. Records were not fully completed, contained inconsistences and were not always reflective of people’s current needs.

People were not regularly supported to access the community. Relatives didn’t feel consistently included in discussions about people’s care. People told us there were no restrictions on friends and family visiting and could go out if they wanted to. One person said, “My [family member] visits and is made to feel welcome.” People confirmed they were supported by a range of different health and social care professionals when needed.

Staff linked in with health and social care professionals when required.

Professionals shared their concerns with us around stimulation, staffing numbers and communication which they felt impacted people living at the home. For example, a professional told us, ‘There have been lots of staffing changes within Maple Court over the past 2 years; there appears at times to be lack of communication between staff members and often relatives feel unsure of who to speak to with day-to-day questions or queries at the care home.” It was also noted that people can find it difficult to speak with somebody on the telephone.

There was limited evidence to demonstrate professional feedback was sought as part of the quality assurance processes. When feedback had been gathered from people and / or their relatives there was a lack of action planning to show this feedback was used to develop the service. The registered manager did attend internal managers meetings along with a weekly multi-disciplinary meeting to discuss people’s care needs and raise any issues.

Although staff and leaders advised of the ways learning was shared we found this had not been effectively implemented to drive improvements within the service. Daily meetings were used as an opportunity to update one another about, accidents, incidents, notifiable events and how people were. Staff meetings were used as an opportunity for further learning. The registered manager noted new initiatives they were trialling and considering to aid staff learning and improvement within the service.

A system was in place to record significant incidents within the service and to monitor potential risks for people such as infections, pressure sores or weight changes. However, as previously noted, whilst there was consideration to lessons learnt further actions were needed to ensure appropriate actions had been taken. Further work was required around involving and utilising the information shared by people and their relatives. There was limited evidence of innovation within the home.