CQC report explained · a residential care home
What the CQC found at Mayfield Residential Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risk assessments were in place, but one care plan contained conflicting instructions about the number of staff needed. Recruitment checks and learning from accidents and incidents also needed improvement.
- Effective?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Caring?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward, although people and relatives gave positive feedback about staff.
- Responsive?
- Good
- This area was not inspected during this focused visit. Its previous rating was carried forward.
- Well-led?
- Requires improvement
- Management and quality monitoring were inconsistent. Audits existed, but they had not identified the risk and recruitment issues, and records did not always show what action had been taken.
What inspectors found, July 2021
Requires Improvement; inspectors found caring staff and safe medicines support, but unclear risk guidance and weak checks on management systems increased safety risks.
This was a focused inspection on 25 and 26 February 2021. The inspector spoke with five people, three relatives and seven staff. They reviewed care, medicines, recruitment and management records, including infection control arrangements.
The home had enough staff, and staff were trained to provide care and give medicines. People and relatives described staff as caring and friendly. Infection control arrangements were also found to be suitable.
Inspectors found important weaknesses. One care plan gave conflicting information about how many staff were needed to support a person safely. Checks on staff criminal records were not properly followed up. The home's quality checks had not found these problems, and records did not always show what action had been taken.
The overall rating changed from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three areas were not inspected during this visit, so their previous ratings were carried forward.
Staffing levels
Inspectors found enough staff to meet people's needs, and staff had training for their roles.
“Staffing levels met the needs of people, in line with the providers staffing tool.” from the report
Medicines
People received their medicines safely and in their preferred way. Staff were trained and had ongoing checks of their medicines practice.
“People received their prescribed medicines safely and in their preferred way.” from the report
Infection control
The home had suitable arrangements for visitors, protective equipment, testing, hygiene and managing possible outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Kind and friendly staff
People and relatives gave positive feedback about the caring and friendly nature of staff.
“People and their relatives provided positive feedback on the caring, friendly nature of staff.” from the report
Unclear care guidance
seriousOne person's care plan gave different instructions about whether one or two staff were needed. This could have increased the risk to the person's safety.
“One person's care plan contained conflicting information regarding the number of staff required to support them safely.” from the report
Incomplete recruitment checks
seriousThe provider did not have a system to follow up criminal record checks, and staff appraisals did not include a declaration. The provider could not demonstrate that staff suitability had been fully checked.
“The provider failed to demonstrate they were assured staff were suitable to work with people.” from the report
Weak quality monitoring
needs fixingThe home's monitoring system had not identified the problems with risk management and recruitment checks.
“the provider's quality monitoring system had not identified them.” from the report
Limited learning from incidents
needs fixingThe home recorded accidents and incidents, but there was not enough evidence showing how it used them to prevent them happening again.
“There was a lack of evidence to show how the information was used to learn from events to prevent reoccurrence.” from the report
- 01How do you now make sure each care plan gives clear and consistent instructions about how many staff are needed?
- 02How are criminal record checks followed up now, and how is staff suitability recorded?
- 03How do your quality audits identify problems that may be missed by routine checks?
- 04What changes have you made to show how accidents and incidents are reviewed and used to prevent them happening again?
- 05How can staff raise concerns about management, and how do you check that these routes are working?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 14 July 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.
What inspectors found, September 2019
Rated Good overall, but well-led was Requires Improvement because management oversight and staff morale needed attention.
This was an unannounced, planned inspection on 24 and 25 July 2019. The inspector and an Expert by Experience spoke with people, relatives, staff and professionals. They also reviewed care records, medicines records, training information and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines management, kind care, suitable care plans, activities and support with food, drink and healthcare.
The home was rated Requires Improvement for Well-led. Several staff raised concerns about management and morale. Inspectors also found that quality checks had missed shortfalls in infection control, premises checks and mental capacity assessments, although action was taken and no impact on people was identified.
The overall rating improved from Requires Improvement at the previous inspection. The earlier concerns about the environment, pressure area care, medicines, care plans and staff understanding had been addressed. The report does not list any breached regulations.
Kind care
People and relatives spoke positively about the care. Inspectors found that people were treated with kindness, dignity and respect.
“People and relatives spoke positively about the care that was provided.” from the report
Enough staff
Inspectors found sufficient staff to meet people's needs. Risks such as moving and handling were assessed and monitored.
“There were sufficient staff deployed to meet people's needs.” from the report
Personalised support
Care plans gave staff guidance on providing person-centred care. The home also had activities and supported people to access the local community.
“People had a care plan which guided staff on how to deliver person-centred care.” from the report
Improvement since the last inspection
The home had acted on earlier concerns about the environment, pressure area care, medicines, care plans and staff awareness of policies.
“At this inspection we found that action had been taken to address these issues.” from the report
Management culture
needs fixingSeveral staff raised concerns about management and said this affected morale. The provider was asked to keep the day-to-day culture under review.
“We recommend that the provider keeps the day-to-day culture at the home under review, to check that it is open, positive and person-centred and take action if any concerns are highlighted.” from the report
Quality checks missed problems
needs fixingAudits did not identify some shortfalls in infection control, premises checks and mental capacity assessments. The home took action during the inspection, and inspectors found no impact on people.
“However, the provider's quality monitoring system had not identified these issues.” from the report
Night-time medicines
needs fixingNight medicines were being given by day staff, with an on-call arrangement overnight. Inspectors asked for night staff to receive medicines training so medicines could be given without delay.
“We discussed with the registered manager about the provision of medicines training for night staff so staff were able to administer medicines through the night without any delay.” from the report
- 01What action has been taken since the inspection to improve staff morale and the day-to-day management culture?
- 02How do your current audits make sure that infection control, premises checks and mental capacity assessments are completed correctly?
- 03Have night staff received medicines training, and can they now give required medicines overnight without delay?
- 04How do you make sure mental capacity assessments are specific to each decision?
- 05How are families and residents involved in checking whether improvements have been made?
This was an unannounced planned inspection covering all five CQC questions, including both the care provided and the premises. This explanation was written from the published report of 5 September 2019 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 Mayfield Residential Home
4 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- July 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2019Goodup from Requires improvementSafe: GoodWell-led: Requires improvement
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Good
- February 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
8 can care for a couple. 10 years' experience on average.
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Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.