CQC report explained · a residential care home
What the CQC found at Mayfield Road
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, November 2023
Rated Requires Improvement; inspectors found risks to safety, dignity, staffing, personal care and leadership that the provider must address.
The inspection was unannounced and took place on 2 October 2023. One inspector observed care, spoke with four relatives and six staff, and reviewed care, medicines, staffing and management records.
The home was not always safe, effective, caring, responsive or well-led. Inspectors found concerns about epilepsy records, fire exits, a window, staffing levels, staff training, the condition of the building, dignity, activities and care planning.
The home had an interim manager and no registered manager. A service improvement plan and refurbishment programme had started, but inspectors said improvements were still at an early stage. The provider was found in breach of six regulations.
Healthcare support
People were supported to attend health checks and access a range of healthcare professionals, including neurologists, dieticians and speech and language therapists.
“People were referred to health care professionals to support their wellbeing and help them to live healthy lives.” from the report
Safeguarding
Staff had safeguarding training and understood how to recognise and report abuse. The home worked with other agencies to protect people.
“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report
Family relationships
People were supported to visit relatives and maintain important family relationships. Relatives confirmed they were regularly supported to visit.
“People were supported to visit their relatives at their family home and spend time with their family.” from the report
Consent and capacity
Staff understood people's capacity to make decisions. Capacity assessments, best-interest decisions and applications for liberty safeguards were recorded when required.
“For people that the service assessed as lacking mental capacity for certain decisions, staff clearly recorded assessments and any best interest decisions.” from the report
Epilepsy safety records
seriousRelatives and incident records showed that seizure records were not always accurate. Information about rescue medicines was not always passed on, which could affect safety during family outings.
“Some relatives had concerns about the safety of care provided regarding people's epilepsy.” from the report
Fire exits and window safety
seriousFire exits on the first and second floors opened directly onto a fire escape without an alarm to alert staff. One window was not properly restricted, creating a risk of falls from height.
“Risks to people's safety had not been appropriately assessed and mitigated.” from the report
Staff skills and training
seriousMandatory training and refresher training were incomplete. Only 21% of staff were up to date with medicines training and only 24% with Buccal Midazolam training.
“Overall training compliance for the staff team was at 60%, this included non-compliance with some key training courses.” from the report
Dignity and kindness
seriousInspectors saw limited engagement, people left in set places and meals given without choice or explanation. Meal support was not always compassionate or respectful.
“We observed very few interactions between staff and people that were not task orientated, this included at mealtimes.” from the report
Personal care and activities
seriousCare plans were not consistently updated and did not properly describe preferences, interests or independence goals. People were at risk of boredom because there were few activities or meaningful interactions.
“People did not have a fulfilling and meaningful everyday life.” from the report
Environment and leadership
seriousThe home had damaged walls and furniture, water damage in a bathroom and bland communal areas. Audits were incomplete, and frequent management changes had affected oversight.
“There was not clear leadership and oversight of the service to ensure high quality safe care was consistently provided.” from the report
This was an unannounced inspection covering all five key questions, including the premises and the care provided; the previous targeted inspection in January 2022 looked only at infection prevention and control procedures. This explanation was written from the published report of 7 November 2023 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, January 2022
Inspected but not rated; inspectors found infection control and visiting arrangements in place.
This was an announced, targeted inspection on 11 January 2022. Inspectors looked at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures were affecting the home.
Inspectors were assured that visitors were screened, tested and required to show vaccination evidence and wear masks inside. People who tested positive were isolated, and new admissions were tested and kept in isolation until a negative PCR result.
Staff were observed using protective equipment and following social distancing guidance. The service was also meeting the requirement for non-exempt staff and visiting professionals to be vaccinated against COVID-19.
The service was inspected but not rated. This was not a full inspection of the quality of care across all five areas.
Visitor safety
The home had detailed visiting arrangements, including screening, temperature checks, vaccination evidence, same-day lateral flow testing and mask use inside.
“The provider was following best practice guidance to prevent visitors to the home spreading COVID-19 infection.” from the report
Use of PPE
Staff had access to PPE stations and inspectors observed staff following PPE and social distancing guidance.
“Our observations during the inspection confirmed staff were adhering to PPE and social distancing guidance.” from the report
Safe admissions
New admissions had PCR and lateral flow tests and were isolated until a negative PCR result was received.
“The service users were kept in isolation until they get a negative COVID-19 PCR test result.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current rules for family visits, including testing, masks and vaccination evidence?
- 02How do you manage staffing pressures when staff are absent because of COVID-19?
- 03What testing and isolation arrangements are used for new admissions now?
- 04How do you check that staff and visiting professionals meet the current vaccination or exemption requirements?
- 05When was the home last given a full inspection covering caring, effectiveness, responsiveness and leadership?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19-related staffing pressures; the service was inspected but not rated and the other care areas were not assessed. This explanation was written from the published report of 14 January 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.
Every inspection of Mayfield Road
4 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- November 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2022Inspected but not ratedSafe: Inspected but not rated
- January 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2016Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2015
Registered with the Care Quality Commission on 18 August 2015.
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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