CQC report explained · a residential care home
What the CQC found at The Mayfields Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm, with suitable risk assessments, enough staff, safe medicines systems and good infection control. Inspectors found that incidents were not always analysed systematically, and one safeguarding matter had not initially been considered properly.
- Effective?
- Good
- People's health, nutrition and hydration needs were met, with support from health professionals and trained staff. Mental capacity assessments were completed when needed, but the records were not always detailed or specific enough.
- Caring?
- Good
- People and relatives spoke positively about staff. Inspectors saw warm, compassionate care, with attention to privacy, dignity, independence and involvement in care decisions.
- Responsive?
- Good
- Care was based on people's preferences, communication needs and interests. There were daily activities and support to maintain family and community relationships, but individual care records did not always include all changes in need or patterns of behaviour.
- Well-led?
- Requires improvement
- The management team was approachable, open and supportive, but its audits and monitoring systems did not always identify risks or lead to clear improvements in records and care planning. Inspectors recommended a review of assessment forms and risk monitoring systems.
What inspectors found, May 2020
Rated Good overall, with kind and safe care, but the home was rated Requires Improvement for how it was managed.
This was a planned inspection on 17 and 19 December 2019. The first day was unannounced and the second was announced. Inspectors spoke with people, relatives, staff and a health professional. They observed care and medicines being given, and reviewed care, medicines, staff and management records.
People told inspectors they felt safe and well cared for. Staff were kind, trained and usually available. Medicines were given on time, the home was clean, food and drink needs were met, and people received help from health professionals.
Care was personalised and included activities, family contact and support for people living with dementia. However, some records and checks were not strong enough. Mental capacity assessments, end of life planning and the analysis of incidents and risks needed improvement.
The overall rating was Good, and Safe, Effective, Caring and Responsive were also rated Good. Well-led was rated Requires Improvement, falling from Good at the previous inspection published in 2017.
Kind and respectful care
People and relatives were very positive about staff. Inspectors saw staff respond calmly and sensitively to people who were anxious or distressed, while promoting privacy and independence.
“We saw friendly and warm interactions between staff and people using the service.” from the report
Safe medicines
Medicines systems were organised, staff were trained and their competence was checked. The home also audited medicine records and stock.
“Medicines administration systems were well organised, and people were receiving their medicines when they should.” from the report
Food and health support
People had choices of food and received support for special dietary needs. The home worked with health professionals when people needed additional help.
“People had a healthy, balanced diet which took into account their preferences and any special dietary needs.” from the report
Management checks did not always find risks
needs fixingSome audits did not identify patterns in incidents or risks. Information was held in different places, so it was not always clear how it was analysed or used to improve care.
“We were not assured analysis was always embedded into individual care plans or systematically used to appropriately mitigate risks and inform future practice.” from the report
Mental capacity records
needs fixingThe home completed mental capacity assessments, but some records were not detailed or specific to the decision and time involved.
“However, the records of these assessments were not sufficiently detailed and were not always time or decision specific as required.” from the report
End of life planning
needs fixingThe home did not use a specific advanced care plan form to record people's end of life wishes. The provider agreed to include advanced care planning in scheduled reviews.
“The provider did not use a specific advanced care plan proforma to support end of life care planning” from the report
Delayed missing-person information
needs fixingFor one person at risk of leaving the building and becoming lost, the Herbert Protocol had not been completed within a reasonable timescale. It was completed during the inspection.
“They completed the protocol on request during this inspection.” from the report
- 01How do you now make sure incidents, falls and behaviour patterns are analysed together and reflected in each person's care plan?
- 02How will you record mental capacity assessments so they are specific to the decision and the time involved?
- 03How do you record and review each person's end of life wishes using advanced care plans?
- 04What has changed since the inspection in your audits and risk monitoring systems?
- 05How do you respond if a person living with dementia is at risk of leaving the home or becoming lost?
This was a planned inspection of the care home covering all five key questions, with the previous overall rating from 2017 reviewed. This explanation was written from the published report of 14 May 2020 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, June 2017
Rated Good; inspectors found kind, well-organised care, with some medicines, risk and management records needing attention.
This was an unannounced comprehensive inspection on 23 and 24 May 2017. Inspectors spoke with people living at the home, visitors, staff and healthcare professionals. They observed care, meals and activities, and checked care, medicines and management records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, trained carers, respectful care, individual care plans, activities and strong quality checks.
There were some shortfalls. Medicines stock records did not always match the checks, some risks were not fully reduced, and there was no registered manager in post during the inspection. The home dealt with some issues immediately when inspectors raised them.
Kind and compassionate staff
People and visitors described staff as kind, patient and compassionate. Inspectors saw staff comforting people who became upset or distressed.
“People told us that all staff were kind, patient and compassionate and went out of their way to provide help and support.” from the report
Enough staff
People, visitors and healthcare professionals said there were enough staff. Inspectors saw staff responding promptly and being present around the home.
“There were enough staff to meet people's needs in an individual manner and we saw that staff worked effectively as a team.” from the report
Respectful care and choice
Staff maintained privacy and dignity and encouraged people to make choices and remain as independent as possible.
“The service promoted people's dignity and encouraged independence and choice.” from the report
Individual care
Care plans reflected people's needs and preferences and were regularly reviewed. Inspectors saw staff delivering the planned support.
“People received individual care that had been assessed and regularly reviewed to ensure it continued to meet their needs.” from the report
Quality improvement
Senior managers had oversight of the home, and audits and action plans were used to identify and make improvements.
“The provider had an effective and robust system in place to assess, monitor and improve the service.” from the report
Medicines records
needs fixingInspectors found discrepancies in medicines stock checks. They concluded that people had received their medicines as prescribed, but the issue was a recording problem.
“The service had audited the amount of medicines stock in place for each person however, for the three medicines we checked, discrepancies were identified.” from the report
Unmanaged risks
seriousTopical creams were openly accessible in some people's rooms, creating a possible ingestion risk for people who lacked capacity. One person's difficulty eating and drinking also needed further action.
“However, the service had not fully mitigated the risks around the open access to prescribed topical creams kept within people's rooms.” from the report
No registered manager
needs fixingThere was no registered manager in post during the inspection. A replacement had been recruited and was due to start, while two unit managers and senior managers ran the home.
“The home did not have a registered manager in post at the time of our inspection although one had been recruited and was due to start.” from the report
Activities and orientation
minorSome people wanted more trips out and stimulation. Inspectors also found limited signage and no pictorial images to help people living with dementia find their way around.
“However, we saw that there was little signage in place to further help people orientate themselves and where this was in place, these were in written form with no pictorial images.” from the report
- 01What checks are now in place to make sure medicines stock records are accurate?
- 02How are prescribed topical creams stored so that people who may lack capacity cannot access them?
- 03Who is currently the registered manager, and how is the home being managed while that person is appointed?
- 04What has been done to offer more variety, trips out and activities for people living in the home?
- 05What improvements have been made to signs, pictures and other cues to help people living with dementia find their way around?
This was an unannounced comprehensive inspection covering all five questions about the service. This explanation was written from the published report of 21 June 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 The Mayfields Care Home
3 rated inspections over 5 years: the service has held its Good rating throughout.
- May 2020Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- December 2012
Registered with the Care Quality Commission on 14 December 2012.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
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.