The Maples

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

A range of governance systems were in place at both registered manager and provider level. Regular checks were carried out on all areas of care provision. However, they were not always robust or effective at identifying and addressing concerns about risk management, safeguarding issues, the completion of visits and medicines in a timely way. Concerns with the quality and safety of the service were identified during this assessment which placed people at risk of avoidable harm. This was a breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager told us the values of the service focused on quality, safety and continuity with regards to people’s support. The registered manager advised staff had access to an Employee Assistance Helpline - a mental health helpline where they can access confidential advice and support and also have the support of Cera employed mental health advisors. Staff meetings took place to discuss service delivery and to promote service values and culture.

Staff practice and conduct was checked via spot checks on staff practice, staff supervision and by gathering feedback from people using the service. These processes enabled the management team to ensure that people were treated with kindness, empathy, dignity, respect and compassion. The provider worked with the Local Authority to discuss people’s changing needs and any changes to the support they needed. Staff from the service attended resident meetings held by the housing provider to ensure any feedback about the service was obtained or learned about during these meetings.

The registered manager told us they were supported in post by the provider and felt they had adequate support. They advised they were being supported to improve the service with the help of the provider and senior managers and a service improvement plan was already in progress. Staff spoken with felt well supported by both the registered manager and the management team and told us they were a visible presence within the service. One staff told us, “They have been great with me."

There were policies and procedures in place that outlined staff responsibilities and the context of staff practice in the workforce. This included reference to the culture and values expected of staff members. The management team demonstrated they understood the service and acted with integrity, openness and honesty at all times. There were clear lines of responsibility and delegation in the service.

During supervision, some staff had raised concerns with the registered manager about staff practice. Records showed the registered manager had acted on staff concerns, with appropriate action taken where necessary. Staff spoken with were knowledgeable and spoke confidently about how to raise concerns about people’s care with the registered manager. A staff member told us a staff meeting took place recently and told us they felt able to raise any issues and share their views during the meeting. The management team told us they encouraged and welcomed any feedback from both staff and people using the service. They told us there were systems in place to encourage feedback such as a complaint procedure and regular quality assurance checks on people’s satisfaction with the service both over the telephone and face to face.

The provider had a safeguarding policy in place that included a section on whistleblowing and speaking up about incidences of potential abuse. People's feedback was monitored via spot checks, regular telephone calls and face to face surveys. Examples of these were provided and showed positive feedback. The surveys directly asked people if they felt any improvements to the service could be made which indicated a listening culture. The provider had a complaint spreadsheet in place which recorded basic details about any complaints received and the action taken. We saw evidence complaints were investigated and responded to appropriately by the management team. Some of the complaints we reviewed however were of a safeguarding nature and should have been responded to as such.

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 registered manager advised they were being supported to improve the service with the help of the provider and senior managers and had a service improvement plan in place. A provider audit of the service took place every 6 months and they also had a series of other audits such as the electronic medication (Emar) auditing tool which monitored staff activity on completing medicines administration. The registered manager told us spot checks on staff practice were completed regularly and staff received supervision to monitor performance. There was a clear management structure in place and oversight from senior management. The management team told us they were also able to generate a visit data report that showed whether staff were completing visits on time and for the duration agreed. They provided a visit data report for the purposes of this assessment but were unable to explain why this report showed multiple visits were not completed on time, or for the duration agreed. They were also unable to explain why no effective action had been taken to address this. Some areas of improvements were needed to improve the robustness and response of managers governing and responsible for improving the service.

There were some audit processes in place to monitor the quality and safety of the service. However, these were not always sufficient and where actions had been identified, timely improvements had not always been made. An electronic medication (Emar ) auditing tool was provided which monitored medicine administration on a monthly basis. This system had a built in alert system for missed or late medicines. We saw there were a number of repetitive themes identified on the auditing tool with regards to missed medicines, no stock available and insufficient time intervals between doses. during November 2023 to January 2024 and we found the same again during this assessment. We saw some action had been taken to address individual service user issues but the overall ongoing management concerns and the themes found had not been addressed effectively. The processes in place to check and ensure people's care plans and other records were accurate, up to date and reflective of the support they required were not robust. We saw this was identified as an area for improvement on the provider's service improvement plan but sufficient improvements had still not been made at the time of our assessment. We reviewed records relating to people's planned Vs actual visit times This report showed significant discrepancies in visit times and durations, with multiple late visits or and support not being delivered as planned and agreed to keep people safe. The managers were unable to explain the anomalies with visit times, durations, missed visits and double handling call issues. After our on site visit, they advised action had been taken to improve governance. The above failings were a breach of Regulation 17 (Good Governance) of the Health and Social Care Act as the provider failed to have effective systems in place to monitor and mitigate risks to the quality and safety of the service. This placed people's health and wellbeing at risk of harm.

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

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.