9 May 2022
During an inspection looking at part of the service
Mayfield House is a purpose-built residential care home providing personal care for up to 51 people. The service provides support to older adults and those living with dementia. At the time of our inspection there were 40 people using the service. Mayfield House accommodates people across two separate units, one of which specialises in care to people living with dementia.
People’s experience of using this service and what we found
We could not be assured people had received their medicines as prescribed. Systems in place to ensure the proper and safe management of medicines were not sufficiently robust. The provider’s efforts to address errors/discrepancies had not been effective. We referred these concerns to the local authority for further support.
Staff took some action to reduce potential risks to people. However, risk assessments did not always include enough individualised information about the support people needed to mitigate risks and some risk assessments were not in place where required.
The provider’s governance and oversight systems were not always effective. Despite their audits identifying areas which required improvement, they did not highlight all the issues we found during the inspection.
The premises were safe. However, fire evacuations which considered minimum staffing levels needed to be carried out. Following the inspection, the manager confirmed how they would address this.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Whilst the provider had processes in place for capacity assessments and best interest decisions to be made, gaps in staff knowledge had resulted in these not always being completed correctly in line with the MCA. We have made a recommendation about this.
There were enough staff to respond to peoples' needs during the inspection, however staffing levels varied at times. The provider was unable to demonstrate safe staffing numbers had been established based on the needs of the people being supported. The provider had recruited some new staff and was continuing to recruit. Staff were recruited safely. During the inspection, the management confirmed they would increase staffing numbers and would source a more effective dependency tool.
People were supported by familiar staff who understood their needs and respected their choices and preferences. However, care plans did not always contain enough information to guide staff about people’s care needs, taking account of their individual preferences.
People told us they felt safe living at the home and overall were complimentary about the support they received. Appropriate safeguarding arrangements were in place. Staff received appropriate training and support.
Relatives were positive about the communication at the service and felt well informed. Visiting was taking place in line with government guidance. A new activities coordinator was due to start at the home.
The provider had a quality improvement plan in place which was updated following the inspection to address the issues we identified. Since the last inspection the provider had made some improvements in relation to the management of complaints, some refurbishment of the premises and they planned to implement new electronic recording systems. Managers were responsive and keen to address any areas identified for improvement.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 17 October 2019) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations. The service remains rated requires improvement.
Why we inspected
This inspection was prompted by a review of the information we held about this service.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, responsive and well-led sections of this full report. The provider has taken some immediate actions and provided an action plan. You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mayfield House on our website at www.cqc.org.uk.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to the safe management of medicines, management of risk and good governance at this inspection. We have made a recommendation in the effective section of this report.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.