Mayflower Court

Updated 29 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 2 inspectors and 2 Expert by Experiences, one attended the inspection and the other contact relatives by telephone afterwards. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Mayflower Court is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Mayflower Court is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced. Inspection activity took place between on 12 October 2002 and 16 November 2022, with some aspects of the inspection being carried out remotely.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 11 relatives, 3 people who used the service, 20 staff including wellbeing co-ordinator, care workers, team leaders, deputy managers, managers including the regional medicines manager, registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We observed people’s care and support. We reviewed a range of records. This included 10 people’s care records and multiple medication records. We looked at 3 staff files in relation to recruitment. A variety of records relating to the management of the service, including audits, policies and procedures were reviewed.

Updated 29 June 2023

About the service

Mayflower Court is a large residential care home providing personal care up to a maximum of 80 people. The service provides support to older people who may be living with dementia or have physical difficulties. At the time of our inspection there were 28 people using the service.

Mayflower court accommodates people across four separate units, over two floors. At the time of the inspection only the two ground floor units were being used. The building is purpose built with a central courtyard garden.

People’s experience of using this service and what we found

The management and quality assurance system had been effective at identifying concerns. However, not all these concerns had been resolved. The provider felt the appointment of a new permanent manager would ensure progress was made following a period of instability.

Medicines were not always managed safely at the home putting people at risk of harm. The provider responded in a timely manner and addressed the main areas of concern for medicines following inspection.

There was mixed response from relatives with regards to contact with the service. Improvements were needed to ensure relatives were engaged with the running of the service and reviewing of the care provided to people who used the service.

There was a high use of agency staff, but plans were in place to address this with a recruitment drive with initiatives. Staff could see the improvements with the appointment of a permanent manager and were positive about the future.

The culture within the service was positive and caring. Staff told us they worked well as a team and felt supported by the managers. Staff felt they had received the training, support and supervision they needed to undertake their roles and meet the needs of the people who used the service.

Improvements had been made since the last inspection in relation to providing people with oral health care with staff understanding their role in supporting people with this and seeing improvements in people. Care was provided in a person-centred way and people received care and treatment from health care professionals in a timely manner.

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.

Improvements were also seen in the management of infection prevention and control with the home being visibly clean and good practices in place. People using the service said, “I think it is very clean here. They clean my room every day and I get clean sheets once a week.” Staff used personal protective equipment (PPE) appropriately.

The managers were open and transparent during the inspection process and responded appropriately and responsively to issues raised.

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 inadequate (published 30 November 2021). There were breaches of regulations and conditions were imposed to the service’s registration. The provider submitted monthly action plans and audits as part of the conditions. At this inspection we found some improvements had been made but the provider remained in breach of regulations.

At our last inspection we recommended that improvements were made in person-centred care, safe care and treatment and good governance.

At this inspection we found improvements had been made in a number of the areas found at the last inspection and the conditions imposed at the last inspection had been meet. However, there were still a number of concerns identified within medicine management and the governance of the service needing further development.

This service has been in Special Measures since 30 November 2021. During this inspection due to the provider demonstrating that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced inspection of this service on 1 and 11 June 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, person centred care and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mayflower court 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 safe care and treatment and good governance at this inspection and issued a warning notice to the provider under regulation 12(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.