Mayfield House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, staffing, safeguarding and the premises.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. Staff did not listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff completed accidents records, mainly where people had experienced falls. However, other incidents were not always logged and reported. The registered manager was not aware of some safety incidents which had occurred between people using the service. Whilst staff recorded these in people’s daily notes, these had not always been escalated or reported under local procedures.

Where staff had reported incidents, the registered manager undertook a monthly audit. However, they had not always undertaken further analysis to reduce recurrence or learn lessons. For example, one person had experienced a fall, records indicated they were found next to their bed and their sensor mat in place to alert staff was not sounding. There was no record of any consideration about whether further action was needed to ensure the alarm was working or whether this was an effective strategy. Where people were at risk of falling, sensor alert mats were generally provided, however other alternative strategies and technologies had not always been considered.

Where complaints had been raised, the registered manager investigated these openly, they sometimes looked to learn lessons and reviewed systems. Staff told us information was sometimes shared with them in response to incidents.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People’s care records were not always comprehensive and up to date, especially where their needs may have changed. This meant staff and healthcare partners may not have access to robust information and guidance about people’s care and health needs. For example, following a hospital admission, one person required support to stand and was now using a wheelchair, however, their care plan had not been updated to reflect this change. The registered manager had recently reintroduced daily staff meetings to help improve communication, including discussions about people who were moving into the service.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

A safeguarding policy and procedure was in place, however the provider did not ensure staff always followed this. Systems in place were not robust and did not always safeguarded people from the risk of harm and/or abuse. The registered manager had reported various safeguarding concerns to the local authority. However, we identified other incidents which had not been reported. The registered manager was not aware of these safety incidents, which meant no further action had been taken to reduce the risk of harm. We made safeguarding referrals to the local authority in relation the concerns we identified. The registered manager also reviewed the records to ensure any other concerns had been fully reported.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We were not assured risks to people were fully assessed and safely managed or that people were appropriately protected from risk of avoidable harm. This included risks related to falls, moving and handling and risks associated with people’s behavioural needs.Whilst staff recorded various risk assessments within people’s care records, they did not always identify actions required to mitigate potential risks. This was especially the case where people living with dementia displayed distressed behaviours and/or agitation towards other people.

Where staff undertook risk assessments and recorded care plans relating to service users’ mobility needs, these were not always up to date or provided sufficient guidance about actions required to mitigate the risk of falls. For example, one person used a walking stick which had broken, their risk assessment had not been updated to reflect this or consider further actions that may be required.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider had not undertaken an assessment of the environment to ensure any safety issues were identified and addressed. Whilst the registered manager undertook monthly health and safety audits, these had not identified all the concerns found. Records described a person to be at high risk of “absconding”. However, there was no recorded risk assessment in relation this or consideration of the security of the garden and/or outside areas to further mitigate any risks. The registered manager confirmed they would ensure an overall assessment was undertaken.

Some people spent their day in the unit designated for people living with dementia, but their bedrooms were in the larger Lavender unit, this meant they were able to access the lift at night. Where people were able to use the lift independently and access areas of the building, staff had not assessed any potential risks in relation to this.

Staff had undertaken monthly audits of bedrooms, but these had not identified the concerns identified, such as a small electric radiator stored in an ensuite bathroom and a loose electric wall socket. The registered manager addressed these issues straight away. Whilst 2 shower rooms had been refurbished, other bathrooms and communal areas needed refurbishment and redecoration.

Following a local fire service inspection in March 2025, the registered manager had focused on staff training and evacuation procedures and drills. All actions had been completed as required. However, during our assessment, we identified some further risks. Staff had wedged open 2 bedrooms doors, which meant they wouldn’t close automatically in a fire and could compromise safety. The provider had recently arranged for several new doors to be fitted following a fire risk assessment. They agreed to take further action to arrange for doors to be adjusted to ensure they could be left open safely. Where people were prescribed emollient based creams, the provider had not assessed the fire risks associated with the use of these, especially where people smoked.

The provider had ensured various other environmental safety checks were carried out and the maintenance of equipment was routinely undertaken.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staff were not always sufficiently trained, supported, or deployed effectively to ensure people’s needs were met. The home was separated into 2 units. Lavender Unit and a smaller Magnolia Unit, designated for people living with dementia. Staff were not always deployed in a way to enable them to always respond to people’s immediate needs. One staff member was always required to stay in the Magnolia lounge, however this meant when other staff weren’t available, they may not be able to respond to people’s needs effectively. For example, records indicated a person had been distressed in their bedroom, but the staff member couldn’t attend to them, as they could not leave the lounge.

We received mixed feedback from people and visitors about the staffing. People said, “The staff are good, although they could use a few more at times” and “I get on with all the staff. I'd say there are usually enough, but they are very busy at times.” One visitor commented, “I think there’s not enough of them, when one goes off the unit, I often end up going to residents.”

The provider had not ensured staff were suitably trained and skilled to support people living with dementia, especially those who may experience behaviours which may challenge. Staff undertook an induction and eLearning training in various topics. Whilst staff undertook dementia eLearning this did not equip staff with the necessary skills. The registered manager told us they had already identified the need for this training and was in the process of arranging this.

Staff were supported with supervision meetings and appraisals, however the registered manager confirmed these had not always been carried out in line with the provider’s policy and was addressing this. Overall, staff told us they felt supported by the management team and were able to seek guidance where required.

Overall, systems were in place to ensure staff were recruited safely. However, we found some gaps in records relating to recruitment requirements. For example, one person’s full employment history was not recorded and a reference from their last employer was not on file. The registered manager said this had previously been obtained but agreed to re-request this and this was provided during the assessment.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The registered manager had been addressing recent issues in relation to the cleanliness of the environment. There had been some staff changes and new cleaning schedules were being put in place, with planned monitoring. However, some bathroom areas and equipment needed more robust cleaning. During our assessment PPE was available for staff, however, we observed a couple of examples where staff had not followed practice guidance in relation to the removal and disposal of gloves.

A recent audit had been undertaken by the local infection prevention and control team. This assessed the service as 91% complaint with the audit requirements, and the registered manager was working on an action plan to comply fully.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Overall, systems were in place to ensure people received their medicines as prescribed. However, we found some gaps in records and areas where staff needed to follow procedures more robustly. For example, where people were prescribed medicines ‘As required,’ protocols were in place to guide staff about when to administer these, however, not in all cases.

Staff had not always recorded the dates creams or eyedrops were opened. In one case we observed eye drops which should have been disposed of after 28 days were still in use, this meant they may not be effective. Where people were prescribed topical and/or barrier creams, staff recorded this on a chart in their bedroom. However, we found staff were not applying all prescribed creams to one person and required charts were not in place. The registered manager addressed these issues straight away when we brought this to their attention.