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.
What inspectors found, October 2019
Mayflower Court rated Requires Improvement; inspectors found safe, kind care, but staffing, activities, food and records were not consistently good.
This was an unannounced comprehensive inspection over three visits. Inspectors spoke with people living in the home, relatives and staff. They observed care, activities, mealtimes and medicines, and reviewed care, medicines, staff and management records.
The home was rated Good for Safe and Caring. Inspectors found people were protected from abuse, medicines were managed safely, the home was clean, and staff treated people with kindness and respect.
The home was rated Requires Improvement for Effective, Responsive and Well-led. High use of agency staff affected continuity, people's choices, activities and response times. Some assessments and records were incomplete or unclear, and people gave mixed views about food and complaints.
The overall rating fell from Good at the previous inspection, published on 31 March 2017. Inspectors said the home had an improvement plan and had stopped new admissions and closed one floor while it worked to improve staffing.
Protection from harm
Inspectors found robust safeguarding systems and staff who understood how to report concerns. Risks were assessed and managed, including environmental and falls risks.
“There were robust systems and processes in place to protect people from the risk of abuse.” from the report
Safe medicines
Medicines were stored, administered and monitored safely. Staff who gave medicines were trained and had their competence checked.
“Medicines were managed safely and there were good procedures in place to ensure people received their medicines as prescribed.” from the report
Kind and respectful care
Inspectors saw staff speaking respectfully and supporting people gently. People were involved in decisions and their privacy, dignity and independence were respected.
“We observed kind and caring interactions between staff and people they were supporting, including agency staff.” from the report
Access to healthcare
The home worked with healthcare professionals and made referrals when needed. Advice from other professionals was included in people's support plans.
“The service worked with other healthcare professionals and organisations to ensure people had access to care which met their needs.” from the report
Improvement planning
Managers recognised the home's difficulties and had clear actions covering recruitment, supervision, assessments, training and agency staff.
“There was a clear improvement plan in place, which identified clear actions to address areas such as staff recruitment, staff supervision and support, updating risk assessments, improving staff training compliance, and ensuring agency staff were aware of people's needs.” from the report
Heavy reliance on agency staff
needs fixingAgency staff regularly made up more than half of the staff on duty. This affected continuity and meant staff did not always know people well enough to provide their preferred care.
“Regularly, agency staff made up more than half of the deployed staff on duty.” from the report
Preferences and activities not always met
needs fixingStaffing sometimes meant people were offered a shower or wash instead of a preferred bath. Activities for more active people were limited, and trips out were not provided.
“Although people's needs were met, sometimes their preferences could not be, such as their preference to have a bath rather than a shower or wash.” from the report
Food quality was inconsistent
minorPeople said food quality varied and some requested items were not always available. Inspectors rated the Effective question Requires Improvement partly because of these concerns.
“People fed back that the quality of food was varied.” from the report
Records were not always reliable
needs fixingSome daily records had gaps and night checks did not show clear times. This made it difficult to confirm whether care and checks had happened as planned.
“Some paperwork was not completed clearly and accurately, or in line with support plans.” from the report
- 01How many permanent staff are now working in the home, and how often are agency staff used?
- 02How do you make sure agency staff understand each person's risks, preferences and care plan?
- 03How are baths, morning care and help with the toilet prioritised during busy periods?
- 04What activities and trips out are currently available for people who are more active and independent?
- 05How are care records, risk assessments, nutrition checks and complaints now reviewed to make sure action is taken?
This was an unannounced comprehensive inspection covering all five key questions, and the CQC looked at both the premises and the care provided. This explanation was written from the published report of 10 October 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.
What inspectors found, March 2017
Rated Good; inspectors found safe, kind and personalised care, with some records and communication needing improvement.
This was an unannounced inspection on 22 and 27 February 2017. Inspectors spoke with people living in the home, relatives, health professionals and staff. They observed care and checked care plans, medicines, staffing, complaints, incidents and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable training and detailed care plans. People were treated with kindness, dignity and respect, and were offered food, activities and healthcare suited to their needs.
There were some minor shortfalls. An emergency list was out of date, the supervision records were not kept in one up-to-date place, and written explanations after some incidents had not been provided. A feedback survey was also returned late. The manager took action on some issues during or after the inspection.
Kind and respectful care
Inspectors saw warm, unhurried interactions. Staff knew people well and protected their privacy, dignity and independence.
“People were cared for with kindness and compassion.” from the report
Personalised care
Care plans described people's needs, preferences and histories. Staff understood this information and responded when people's needs changed.
“People received personalised care and support. Staff demonstrated a good awareness of people's individual needs and responded effectively when their needs changed.” from the report
Food and nutrition
People could choose meals and receive snacks and drinks when they wanted them. Staff provided kind support with eating and drinking when needed.
“People received a varied and nutritious diet and they were supported appropriately to eat.” from the report
Activities and relationships
The home offered group and one-to-one activities based on people's interests. Visitors were welcomed and people were supported to maintain important relationships.
“People were offered an extensive range of activities suited to their individual needs and interests providing both mental and physical stimulation.” from the report
Quality monitoring
The home carried out regular checks on areas including medicines, care planning, infection control and staff training. These checks were used to identify and address improvements.
“Auditing of all aspects of the service, including care planning, medicines, infection control and staff training was conducted regularly and was effective.” from the report
Emergency information
needs fixingThe list of people living at the home was not up to date, which could have delayed emergency teams. The manager arranged for it to be updated during the inspection.
“We identified however, that the list of people at the home had not been updated meaning emergency teams could waste time looking for a person who was no longer at the home.” from the report
Written explanations after incidents
needs fixingThe home had spoken with relatives after accidents or incidents but had not always provided the required written explanation. The manager said the process would be clarified and followed in future.
“However, they had not followed the full duty of candour and provided a written explanation of the event to the person or their relatives.” from the report
Staff supervision records
minorThe supervision tracker was not kept up to date, so the manager could not immediately confirm that supervision had taken place or met the expected standard. Records sent after the inspection showed most staff were receiving regular supervision.
“However, the heads of care had not ensured the supervision matrix which recorded completed supervisions was kept up to date.” from the report
Delayed feedback survey
minorThe manager received the results of an external survey several months after it was completed. The provider had identified this delay and said it was being addressed.
“The registered manager had only received the response from this survey in February 2017 meaning they would not have been promptly aware if people had raised any areas of concern.” from the report
- 01How do you now keep the emergency list up to date, and when was it last checked?
- 02How are written explanations provided to people and relatives after accidents or other incidents?
- 03How do you record and monitor staff supervision now?
- 04What was done to prevent delays in receiving feedback from surveys?
- 05How do you check that staffing remains sufficient when people's needs change or new people are admitted?
This was an unannounced first comprehensive inspection covering all five questions and the overall quality of the home. This explanation was written from the published report of 31 March 2017 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
2 rated inspections over 3 years: the service has slipped, from Good to Requires improvement.
- October 2019Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2015
Registered with the Care Quality Commission on 7 September 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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