CQC report explained · a residential care home
What the CQC found at Mayflower Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Medicines were not always given as prescribed, and staff did not always follow medicines procedures. The home also had concerns about covert medicines, seizure records, fluid records and some unlocked bathroom cabinets.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- Care plans were person-centred and staff understood people's preferences and communication needs. Oral health support had improved, although some people were not positive about the regular activities offered.
- Well-led?
- Requires improvement
- Quality systems identified some concerns but had not resolved all of them. Monitoring of medicines, safeguarding, DoLS authorisations and fluid intake needed to improve, and relatives were not always involved enough.
What inspectors found, June 2023
Rated Requires Improvement; inspectors found unsafe medicines management and weak oversight, although care planning and the culture had improved.
This was an unannounced focused inspection. Inspectors spoke with people, relatives and staff, observed care, and checked care, medicines, staff and management records. They inspected Safe, Responsive and Well-led only.
The home had improved since its previous rating of Inadequate. Care was more person-centred, oral health support had improved, and infection control was better. However, medicines were not always given safely, and some risks were not properly recorded or managed.
The home had a positive and caring culture. Staff felt supported, but there had been several changes of manager and a high use of agency staff. Relatives were not always involved in care reviews or the running of the home.
The overall rating is Requires Improvement. The home was previously in Special Measures, but it is no longer rated Inadequate and has left Special Measures. The provider remained in breach of regulations and received a warning notice about medicines.
Person-centred care
Care plans included people's histories, needs and preferences. Staff could explain how individuals liked to be supported.
“Care planning was person centred with details of the person's life, needs and preferences, including past history and life events.” from the report
Improved oral health
The home had made progress with oral hygiene. Staff had training and a dentist visited regularly.
“Since the last inspection oral hygiene had improved.” from the report
Caring culture
Staff described the culture as positive and caring. They felt supported by managers and able to raise concerns.
“The service had a positive culture which was person-centred, open, inclusive and empowering.” from the report
Health professional involvement
Regular meetings with health professionals improved access to advice and helped review care and medicines.
“Every fortnight there was a full multi-disciplinary team (MDT) meeting to review people's care and their medicines.” from the report
Medicines were not always safe
seriousSome people did not receive medicines as prescribed. Staff did not always follow procedures, and records and arrangements for covert medicines and seizure emergencies needed improvement.
“People did not always receive their medicines as prescribed. Staff were not always following the prescriber's instructions when administering medicines.” from the report
Weak quality oversight
seriousAudits found some problems but did not always lead to them being fixed. Monitoring of several safety areas needed stronger management oversight.
“Systems had not been completely established to help monitor and improve the quality and safety of the service.” from the report
High agency staff use
needs fixingMany staff were from agencies because of vacancies. Inspectors and relatives were concerned this could affect continuity and whether staff knew people's needs.
“There was a high use of agency staff, but plans were in place to address this with a recruitment drive with initiatives.” from the report
Relatives not always involved
needs fixingRelatives were not always engaged in the home or in reviewing people's care. The manager had identified this as an area needing improvement.
“Relatives had not always been engaged with the service and reviews of the care of people who lived there.” from the report
- 01What changes have been completed to make sure every medicine is given exactly as prescribed?
- 02How are covert medicines now reviewed, authorised and recorded, and how do you make sure medicines are offered openly first?
- 03What new checks are in place for people who may have an epileptic seizure, and when were staff last trained?
- 04How are you reducing agency staffing and making sure agency workers understand each person's care plan?
- 05How will relatives be involved in care reviews and in raising or resolving concerns?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their ratings carried over from the previous inspection. This explanation was written from the published report of 29 June 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, December 2021
Rated Inadequate and in special measures; inspectors found serious safety, care and management failures.
This was an unannounced focused inspection about falls and management. Inspectors widened it to include how well the home responded to people's needs. They visited between 1 June and 11 June 2021, spoke with relatives and staff, observed care and checked records.
The home was not safe. Medicines were not always managed properly. Inspectors also found poor cleanliness, unsafe infection control practices and unanswered fire safety concerns. Safeguarding alerts were raised with the local authority.
Care was not always personal or respectful. Oral care was inconsistent, some relatives said their concerns were not heard, and records did not show that people's choices and needs were always met. Inspectors also found that leaders had not identified or fixed repeated problems.
The overall rating fell from Good to Inadequate. The home was placed in special measures, and CQC required an action plan and said it would return to check for significant improvement.
Some kind staff
Inspectors saw that most staff were kind and caring. Some relatives also had no concerns about the quality and safety of care.
“Whilst we observed the majority of staff to be kind and caring” from the report
Activities and relationships
People were supported to choose activities, spend time in the garden and keep in touch with family through video calls.
“We observed staff engaging with people with choosing activities they wanted to do” from the report
End of life visits
People receiving end of life care could have visits from relatives. Staff training was available in end of life support.
“People were supported to receive visits from their relatives when receiving end of life care” from the report
Visitor screening
Visitors were screened for COVID-19 symptoms, and the report says staff were courteous and friendly to relatives.
“Staff were carrying out appropriate screening on visitors for COVID-19 signs and symptoms” from the report
Medicines were not safe
seriousThere were missing fridge temperature records, expired eye drops still in use, gaps in medicine stock records and missed doses that were not always reviewed. One medicine packet also revealed a person's name when thrown away.
“People did not always receive their medicines safely, and systems and oversight measures for medicines were not effective.” from the report
Infection control and cleanliness
seriousPPE was stored incorrectly, cleaning was not thorough and some equipment and laundry areas were dirty. Staff did not always follow COVID-19 safety measures.
“Poor standards or cleanliness and lack of adherence to COVID-19 government guidance placed people at risk of harm through infections.” from the report
Personal care and dignity
needs fixingOral care was not consistent. Inspectors also found continence products stored in bedrooms and shared bathrooms in ways that did not protect privacy or dignity.
“Oral care was not being monitored or provided consistently placing people at risk of infections in their mouth” from the report
Concerns were not consistently heard
needs fixingRelatives gave mixed feedback. Some described poor communication, delays in answering calls and concerns about falls, staffing, personal care and missing belongings.
“We received mixed feedback from relatives about communication from the service.” from the report
Weak leadership and learning
seriousManagers did not have effective systems to monitor quality and safety. Problems identified in earlier inspections and audits, including medicine temperature records and fire safety, had not been properly resolved.
“There was no system in place which ensured the registered manager and provider could demonstrate the quality and safety of the care provided was being sustained.” from the report
- 01What has been done to make medicine storage, fridge temperature checks, stock counts and missed doses safe?
- 02What changes have been made to cleaning, PPE storage, laundry areas and staff infection control practice?
- 03Have all fire risk assessment actions been completed, including replacing condemned extinguishers and training staff to use evacuation chairs?
- 04How are oral care, continence support, fluids and people's personal care needs now checked and recorded?
- 05What evidence can you show that complaints, safeguarding concerns and previous inspection findings are now acted on promptly?
This was a focused inspection of Safe and Well-led, widened to include Responsive; Effective and Caring were not inspected and their previous ratings were carried over. This explanation was written from the published report of 1 December 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 Mayflower Court
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- June 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2021InadequateSafe: InadequateResponsive: Requires improvementWell-led: Inadequate
- April 2021Inspected but not ratedSafe: Inspected but not rated
- July 2018Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
- June 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- April 2016
Registered with the Care Quality Commission on 12 April 2016.
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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13 live-in carers within about an hour of Norfolk
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.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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.