CQC report explained · a residential care home
What the CQC found at Mayfair Residential Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, medicines were stored and given safely, staffing levels were sufficient and infection control arrangements were thorough. People said they felt safe.
- Effective?
- Good
- This key question was not inspected in detail during this focused inspection. Its previous rating was used to calculate the overall rating.
- Caring?
- Good
- This key question was not inspected in detail during this focused inspection. Its previous rating was used to calculate the overall rating.
- Responsive?
- Good
- This key question was not inspected in detail during this focused inspection. Its previous rating was used to calculate the overall rating.
- Well-led?
- Good
- Inspectors found effective checks and audits, clear management responsibilities and a positive, person-centred culture. People and staff said managers were visible, approachable and supportive.
What inspectors found, April 2022
Mayfair Residential Home Limited is rated Good; inspectors found major improvements in safety, medicines, staffing and management.
This was an unannounced, focused inspection on 16 March 2022. The inspector spoke with three people living at the home, five staff members and a provider representative. Records, care plans, medicines, staffing, the building and management systems were also checked.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found that earlier concerns about fire safety, evacuation, medicines, staffing, infection control and management systems had been addressed. People said they felt safe, and staff were available to support them.
This inspection only looked closely at Safe and Well-led. The other ratings were carried forward from the previous inspection. The overall rating improved from Requires improvement to Good, and the home was no longer in breach of regulations.
Fire safety
The home had made substantial improvements to fire safety, including the building, staff training and evacuation arrangements. Inspectors were assured that the environment was safe.
“Substantial improvements had been made around fire safety issues seen at an earlier inspection.” from the report
Medicines
Medicines, including controlled drugs and oxygen cylinders, were stored and managed safely. Staff had suitable training and their practice was checked.
“Medicines were stored and administered safely. This included the safe storage of oxygen cylinders.” from the report
Staffing and recruitment
Inspectors found appropriate recruitment checks and enough staff to support people. A revised shift pattern had been introduced after reviewing staffing needs.
“There were enough staff employed. The staffing rotas supported this.” from the report
Management
Management systems had improved and were being used to check care quality and environmental risks. People and staff described managers as approachable and supportive.
“The provider's systems to monitor and oversee the quality of the care and support to people and any environmental risks were effective” from the report
People felt safe
The home had safeguarding processes, staff knew how to report concerns and incidents were reviewed. People told inspectors they felt safe living there.
“People told us they felt safe living in the home.” from the report
Inspectors raised no specific concerns in this report.
- 01How are fire safety checks and evacuation plans kept up to date, and how often are staff refreshed on this training?
- 02How do you check that staffing levels remain sufficient on every shift, including at night?
- 03How are medicines audits carried out, including checks on controlled drugs and oxygen storage?
- 04How do you make sure infection prevention and control procedures continue to be followed during an outbreak?
- 05Which checks and audits do managers use to identify and act on any new risks or shortfalls in care?
This was an unannounced focused inspection of Safe and Well-led; Effective, Caring and Responsive were not inspected in detail and their previous ratings were carried forward. This explanation was written from the published report of 2 April 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, August 2021
Rated Requires Improvement, with Safe rated Inadequate because fire safety, risk management and staff training were not reliable.
This was a focused inspection after concerns from the Fire and Rescue Service. Inspectors visited on five dates in June 2021, spoke with people, relatives and staff, checked the building and equipment, and reviewed care, medicine, training and management records.
Inspectors found serious fire safety problems. Fire doors had been removed, there were holes in floors and ceilings, and the fire evacuation plan was no longer adequate. Many staff had not completed fire safety or evacuation chair training. Window safety, contractor storage, medicines storage and staffing arrangements also needed attention.
The home was rated Inadequate for Safe and Requires Improvement for Well-led. The overall rating fell from Good at the previous inspection. Inspectors found no evidence that anyone had been harmed, but people were exposed to avoidable risks and the home's checks had not found important problems.
The provider began taking action during and after the inspection. Fire doors were replaced, window restrictors were being fitted, staff training had started and improvements to governance were planned. CQC issued warning notices for breaches of Regulations 12 and 17 and said it would monitor progress and return.
Kind interactions
Inspectors saw positive interactions between staff and people. People and relatives said they were happy with the care.
“During the inspection visit, we saw positive and caring interactions between staff and people who lived at the home.” from the report
People felt safe
People told inspectors they felt safe living in the home. Staff also knew the importance of reporting abuse.
“People told us they felt safe living at the home.” from the report
Action started
The provider began responding to the fire safety concerns during and after the inspection. This included replacing fire doors and starting further safety work.
“Following the first day of inspection and subsequent visits, we saw evidence of the registered provider acting and responding to risk.” from the report
Staff communication
Staff told inspectors they felt listened to and supported by senior management. They also described teamwork as strong.
“All staff we spoke with told us they felt listened to and were supported by the senior management team.” from the report
Serious fire safety risks
seriousFire doors had been removed and building works had created breaches that could allow fire, smoke and toxic gases to spread. The evacuation plan was no longer adequate.
“People were not safe in the event of a fire or a fire alarm sounding at Mayfair Residential Home Limited.” from the report
Insufficient emergency training
seriousMany staff had not completed fire safety training, and some had not been trained to use the evacuation chair. Staff had not had practical opportunities to use the equipment.
“Records maintained by the provider demonstrated that seventeen staff had not received fire safety awareness training and three staff had not had any fire training at all.” from the report
Weak management checks
seriousAudits had not identified the serious safety problems found by inspectors. Some evacuation plans and other records were incomplete or inaccurate.
“We were not provided with assurances that auditing systems within the service were consistently implemented and effective.” from the report
Inconsistent infection control
needs fixingCare staff generally used protective equipment appropriately, but inspectors sometimes saw management staff without suitable protective equipment. The provider was asked to make infection control processes more consistent.
“We observed care staff using PPE effectively, however noted there were sometimes when members of the management team were noted not wearing appropriate PPE.” from the report
Medicines storage
needs fixingSome prescribed items and oxygen were not always stored according to the home's policy. A medicines fridge had repeatedly shown a higher than recommended temperature.
“We were not fully assured however that medicines were always stored safely in line with the medicines policy.” from the report
- 01Have all fire doors, floors, ceilings and other building works now been checked and made safe?
- 02Has every staff member completed fire safety and evacuation chair training, including practical use of the chair?
- 03Are every resident's Personal Emergency Evacuation Plans complete, accurate and regularly reviewed?
- 04How are medicines, oxygen and the medicines fridge stored and monitored now?
- 05What evidence can you show that audits now identify safety risks and incomplete records?
This was a focused inspection of Safe and Well-led only; the other key question ratings were not inspected and were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 3 August 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Mayfair Residential Home Limited
5 rated inspections over 7 years: the service has held its Good rating throughout.
- April 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Mayfair Residential Home Limited →
- August 2021Requires improvementSafe: InadequateWell-led: Requires improvement
Read what inspectors found at Mayfair Residential Home Limited →
- February 2021Inspected but not ratedSafe: Inspected but not rated
- December 2018Goodup from Requires improvementSafe: GoodWell-led: Good
- November 2017Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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