Archived: Mayfield House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulations in relation to governance at the service and notifying CQC of events as required.

This service scored 54 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The registered manager had been working with staff to develop a shared direction. Meeting minutes demonstrated the management team were guiding staff with their expectations and encouraging staff to compete the required training. The registered manager told us this was a work in progress. They were introducing new values for the service and staff had been involved in the development of the values to be adopted.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Overall, people and staff were positive about the leaders of the service. The registered manager was approachable and accessible. We found them to be open and transparent throughout the assessment. They were responsive and took some immediate actions in response to our findings. They demonstrated they were keen to develop and improve the service.

The registered manager’s role included a significant number of responsibilities. They had not recently had the support of an administrator or deputy manager. Recruitment was currently in progress, with the aim of appointing an administrator and new care plan coordinator role, which the registered manager hoped would enable them more time to focus on leadership and strategic tasks.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider had a whistleblowing policy in place. Various meetings were held, where staff were given the opportunity to share their views. Staff we spoke with told us they felt able to raise any concerns should they need to.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had an equality and diversity policy in place. Staff had undertaken equality and diversity training. Feedback from staff indicated they were treated fairly and the registered manager worked towards an inclusive approach.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider failed to ensure effective systems to assess, monitor and improve the quality and safety of the service provided were in place. Whilst staff undertook various audits, governance systems were ineffective because they had either not highlighted or fully addressed the concerns we identified during the assessment. We identified issues in relation to the deployment of staff; training and supervision; safe management of risk, safeguarding people, suitability of the premises; providing person- centred care and the need for consent. The registered manager was not aware of all aspects of risk within the service.

Care plan audits were undertaken, whilst these audits identified some areas for improvement, with actions identified, we found these audits had not effectively identified and addressed all the issues we found. Care plans were not fully reflective and up to date in relation to people’s support needs.

The registered manager was addressing some concerns about the accuracy of staff record keeping, highlighted following an incident within the service. The provider had not undertaken any monitoring audit visits. However, prior to our visit they were in the process of arranging a mock inspection. The registered manager provided a service improvement plan, however this lacked detail about the specific actions required, and who would be responsible for these.

The provider’s governance and oversight had not ensured all legal and regulatory requirements had been met. They were in the process of installing CCTV. However, the provider had not undertaken a data protection impact assessment prior to going ahead with the installation. The registered manager shared the provider’s CCTV policy; however, this did not include all information in line with the Information Commissioner’s Office guidance on data protection.

The provider had not ensured CQC were notified of all incidents as legally required. Whilst we had been advised of several incidents, we identified some events which we had not been notified about. The registered manager submitted these when we brought this to their attention.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The registered manager worked openly with health and social care partners. They collaborated with various external audits to help identify shortfalls and had taken some action in response. We spoke with a visiting health professional who told us the registered manager was receptive to their input and engaged with suggestions for improvement.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

At our previous inspection we identified two breaches of the relevant regulations. We found further breaches of regulation at this assessment. Whilst the registered manager, was reactive and responded to concerns raised by us, the provider had not been sufficiently proactive in the development and improvement of the service.