We carried out a review of the data available to us about Mayfair Residential Home Limited on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Mayfair Residential Home Limited, you can give feedback on this service.
Mayfair Residential Home is a residential care home registered to accommodate up to 45 people in need of personal care. Accommodation is provided over three floors with single rooms and three double rooms. On the day of the inspection, there were 30 people living at the home.
People’s experience of using this service and what we found
Substantial improvements had been made around fire safety issues seen at an earlier inspection. This included structural measures, staff training and evacuation processes. Other environmental safety concerns had been addressed and we were assured the environment was safe.
Medicines were managed and stored safety. People received their medicines as prescribed by health care professionals.
Staff were recruited appropriately and there were robust systems to ensure they were safe to work with vulnerable people. There were sufficient staff available to support people.
People were protected from abuse and they said they felt safe living in the home.
Infection, Prevention and Control (IPC) processes were thorough. We were assured about the service's ability to mitigate the transmission of infections.
Safe visiting processes were in place to ensure people could see visitors when they wished and could maintain relationships that were important to them.
The home worked in partnership with other organisations and relatives to provide effective and consistent care.
People were happy with the way the service was managed. Staff and people's views and opinions of the service were sought and acted on.
The provider had a system of checks and audits to make sure the service provided consistently good care and support to people. There were robust and up to date policies to guide staff and management about how people should be supported and how the service should be run.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was 'Requires improvement' (published 30 July 2021). The service was in breach of the regulations.
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 improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This inspection was carried out to follow up on improvements we told the provider to take at the 2021 inspection. As a result, we undertook a focused inspection to review the key questions of 'Safe' and 'Well-led'. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
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.
The overall rating for the service has changed from 'Requires improvement' to 'Good' based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mayfair Residential Home on our website at www.cqc.org.uk
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information, we may inspect sooner.
Mayfair Residential Home Limited, (Mayfair) is a residential care home providing personal and care to older people. At the time of the inspection, 29 people were receiving regulated activities at the home. The service can support up to 45 people. The home is an adapted building with two lounge areas and a dining room on the ground floor. Bedrooms are based over three floors. There are no ground floor bedrooms at the home.
People’s experience of using this service and what we found
People were not always safe. People were not safe in the event of a fire or a fire alarm sounding at Mayfair Residential Home Limited. Risk was not always appropriately identified, assessed and managed in a timely manner. At the beginning of the inspection we identified substantial and widespread failings in respect of fire safety arrangements and in the leadership and governance of the service to prevent, identify or address these shortfalls. In addition, not all staff had been trained in fire safety and had not received instruction or had experience of using equipment which was central to fire evacuation processes. Health and Safety guidance developed to keep people safe had not been consistently considered and implemented within the home to keep people safe.
Governance systems within the home were not always robust and had failed to identify all the key concerns regarding safety that we picked up at inspection. Oversight within the home was inconsistent and this had resulted in people being exposed to the risk of harm. Risk assessments designed to promote safety throughout the service were not always followed. The organisation's health and safety policy had not always been followed and implemented. Audits had not been effective and had failed to identify the significant failings identified during the inspection. Paperwork was not always accurate, up to date and complete.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 24 December 2018).
Why we inspected
The inspection was prompted in part due to concerns received from the Fire and Rescue Service about fire safety within the home. A decision was made for us to inspect and examine those risks. Whilst reviewing fire safety within the home we identified additional concerns regarding staff training and governance within the service. As a result, we carried out a focused inspection to review the key questions of safe and well-led only. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
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.
The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.
You can see what action we have asked the provider to take at the end of this full report.
The registered provider has been responsive to concerns noted during the inspection and has started to take action to make improvements and promote safety within the home.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Abbey Mayfair Residential Home on our website at www.cqc.org.uk.
Enforcement
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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to management of risk, deployment of staffing and governance at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
People’s experience of using this service and what we found
The provider was in the process of responding to concerns raised by the Lancashire Fire and Rescue Service. They were looking at purchasing new flooring and fire doors. Staff were able to explain what actions they would take in the event of a fire, to keep people safe. Professional guidance had been sought to review, policies, procedures and individual fire risk assessments for people at Mayfair Residential Home. New evacuation equipment had been purchased and evacuation training drills for all staff had been scheduled.
People were cared for in a clean and homely environment. Infection control systems and audits promoted a clean environment. The premises looked clean and staff confirmed the frequent cleaning of high touch areas such as handles and switches.
Furniture had been rearranged to support social distancing. The service had an adequate supply of PPE equipment. There were designated areas throughout the home, so staff had easy access to personal protective equipment (PPE). Clinical bins and bags were situated throughout the home for the safe disposal of PPE. Regular testing for all people and staff was ongoing by staff who had been trained on how to perform the testing.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 21 December 2018).
Why we inspected
CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.
We undertook this targeted inspection to check on a specific concern we had about fire safety. The overall rating for the service has not changed following this targeted inspection and remains good.
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 coronavirus and other infection outbreaks effectively.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
We received consistently positive feedback from people about Mayfair Residential Home. People told us it was homely, safe and that staff were kind and treated people well.
The service had systems to ensure risks were managed and people were kept safe. Staff had the knowledge and skills to keep people safe from avoidable harm.
People received effective care from a well-supported and trained staff team.
Staff understood the importance of providing person-centred care and treated everyone as individuals, respecting their abilities and promoting independence.
There were enough staff on duty at the right time to enable people to receive care in a timely way. People had opportunity to access a wide range of activities including access to the local community.
Staff had built positive caring relationships with people they supported and their families.
People received personalised care that was responsive to their needs and preferences.
Staff liaised with other health care professionals to ensure people's safety and meet their health needs. Where staff noted a concern they quickly involved healthcare professionals, to achieve positive outcomes for people and reduce any risks.
We received consistently positive feedback about how the service was managed.
A range of checks were completed by staff and the management team to ensure the quality and safety of the service was maintained.
More information is in the full report.
Rating at last inspection: Requires improvement (Report published 04 November 2017). When we last inspected the service, we found the provider was not meeting legal requirements in relation to Safe care and treatment; Safeguarding service users from abuse and improper treatment; Need for consent; and Good Governance. Following that inspection, the provider submitted an action plan telling us how they planned to make improvements for people who used the service. During this inspection, we found the provider had made improvements and was meeting legal requirements.
About the service: Mayfair Residential Home is registered to provide care for up to 45 older people. It is situated on the promenade close to shops, buses, local amenities and the beach. Some bedrooms have en-suite facilities. There are two communal lounges, a sun lounge and a spacious dining area.
Why we inspected: This was a scheduled inspection based on the previous rating and to check what improvements the provider had made following the previous inspection.
Follow up: The next scheduled inspection will be in keeping with the overall rating. We will continue to monitor information we receive from and about the service. We may inspect sooner if we receive concerning information about the service.
At the last inspection on 05 May 2015 the service was meeting legal requirements of the regulations.
Mayfair Residential Care Home Limited is registered to provide accommodation for up to 45 older people who require 24-hour care. The home is situated on Morecambe promenade, close to local amenities and overlooks Morecambe Bay. The majority of bedrooms have en-suite facilities. The are several communal areas, including a large dining room, sun lounge and quiet lounge. The provider operates CCTV in communal areas of the home. At the time of our inspection 37 people lived at the home.
There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Staff had received training to administer medicines, however no checks on their competency had been undertaken. We observed staff left the medicines trolley unattended whilst administering people’s medicines. The provider did not have formal systems to assess the competency of staff who administered medicines. This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Safe care and treatment.
We found the provider had not ensured valid consent was gained before care and support was provided to people. Assessments of people’s capacity to make decisions had not been properly assessed. This was in breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Need for consent.
We found people’s liberty was restricted because they lacked insight into keeping themselves safe outside of the home. However, the provider had not followed proper procedures in order to apply these restrictions in accordance with the Mental Capacity Act 2005 Deprivation of Liberty Safeguards. This was in breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Safeguarding service users from abuse and improper treatment.
The provider’s systems to assess, monitor and improve the quality of the service provided had not been effective in identifying and addressing the issues highlighted during our inspection. This was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Good Governance.
People told us they received personalised care that was responsive to their needs. However, we found people’s involvement in care planning was not always recorded. Although staff knew important details about people, these were not always recorded. We have made a recommendation about this.
The provider used external companies to carry out quality assurance on various aspects of the service provided. However, they had not identified the issues raised above. We have made a recommendation about this.
Relevant checks had been made before two new staff members commenced their employment. These included Disclosure and Barring Service checks (DBS), and references. This helped to ensure only suitable candidates were employed to work with people who may be vulnerable. However, there were occasions where the registered manager was unable to obtain references, or convictions were recorded on DBS checks. There were no related risk assessments available for review. We have made a recommendation about this.
The home was well maintained and generally clean and tidy. However, we found some equipment had not been cleaned properly. We raised this with the registered manager who addressed this during our inspection.
The provider had an ongoing programme of refurbishment for the home to ensure the premises continued to meet the needs of people who lived at the home and it was a comfortable and safe place for people to live.
Policies and procedures were in place and staff had received training in order to safeguard people who may be vulnerable. We found the provider recorded and managed accidents and incidents appropriately.
We found staffing levels and skill mix were appropriate in order for people’s needs to be met safely and in a timely manner.
People were supported by staff who had the right competencies, knowledge, qualifications and skills. Staff received regular supervision and were supported to undertake their role.
People’s ongoing healthcare needs were monitored and met. Good communication protocols were in place between the service and healthcare professionals.
People who lived at the home, and relatives and friends who were visiting, were complimentary about the staff team and how caring the service was.
The home supported people who required care toward the end of their lives. People’s end of life wishes had been recorded so staff were aware of these and could support the person appropriately.
The service provided a range of activities in order to promote people’s social health. People could choose how they spent their time.
The provider had a complaints policy. People told us they were confident any complaints would be dealt with appropriately.
Staff had clear roles and responsibilities. Staff told us they were well supported by the management team.
You can see what action we have told the provider to take at the back of the full version of the report.
The inspection visit at Mayfair Residential Home took place on 05 May 2015 and was unannounced.
Mayfair residential care home is registered to provide care for up to 45 older people who do not require nursing care.
The home is situated on the Promenade close to shops, buses and local facilities and the beach. All bedrooms are single occupancy with the exception of one twin room for couples wishing to share. Over half the bedrooms are en-suite. There are several shared communal lounges and dining areas. At the time of the visit there were 35 people who lived at the home.
There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
At the last inspection on 17 January 2014 the service was meeting the requirements of the regulations that were inspected at that time.
People who lived at the home told us they felt cared for, safe and secure. People’s care and support needs had been assessed before they moved into the home. Care records we looked at contained details of their preferences, interests, likes and dislikes. Relatives we spoke with told us they had been consulted about their relative’s care and were informed of any changes that occurred. People who lived at the home told us their views and choices were listened to by the staff and registered manager.
We saw there were safeguarding policies and procedures in place. Staff we spoke with were knowledgeable about the actions they would take if they witnessed any abuse taking place. Sufficient staff were on duty to enable people to move around the building safely and staff were available to support people. One person who lived at the home said, “There is plenty of staff around if I need someone.”
We observed medication being administered in a safe manner. We observed the person administering medication one person at a time, to minimise risks associated with this process.
Staff were trained well and they told us access to attend courses were supported by the management team. The staff members we spoke with told us they discussed their training needs in their regular formal supervision sessions. These were one to one meetings with their manager. Records demonstrated these meetings were held on a regular basis.
Staff we spoke with had a good understanding of how people should be treated in terms of respect and dignity. During the day and as part of our observations we saw examples of staff being respectful, caring and sensitive towards people who lived at the home.
We found examples where the home had responded to changes in people’s needs. We saw referrals had been made to external professionals. Records were up to date and reviewed providing information for staff to deliver quality care.
People who lived at the home were encouraged and supported to maintain relationships with their friends and family members. Relatives we spoke with told us they were always made welcome at any time.
We found a number of audits were in place to monitor quality assurance. Records demonstrated identified issues were acted upon in order to make improvements. The registered manager and provider had systems in place to obtain the views of relatives and people who lived at the home.
People told us that they were happy at Mayfair residential home. They said that they received care and support when they wanted it. We observed people who lived in the home being treated with respect and dignity in a friendly and caring way. People told us that the staff were kind and caring. One person told us, 'We are blessed with very good staff.' Another person said, 'I couldn't fault the care I receive here.'
We talked with some people's relatives to find out their views of the home. One relative said, 'We are so pleased with the way Mum is looked after.' Another relative told us, 'I think the staff are marvellous, Mum looks better than I have seen her for a long time.'
People told us that the meals were good. We saw staff assisting and encouraging people with their meals as needed. They were attentive and supported people appropriately.
The home was maintained and equipment was serviced regularly so that it was safe for people to use.
People who lived in the home and relatives told us that they were well supported by the staff team. They told us that if they were unhappy with anything staff listened and acted on this.
Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People were smartly dressed, well groomed and wearing clean and comfortable clothing. Appropriate aids and adaptations were available to assist people.
We observed staff interacting with people during our visit. Staff supported people living in the home well. We observed people over lunch time and later in the afternoon. Staff assisted people sensitively and unhurriedly, giving help or encouragement where it was needed.
People living in the home were praising about the care and support they received. One person said, "The staff are excellent here. I wouldn't want to be in any other home." Another person said, 'I am glad I came here now. The staff have helped me a lot.'
Most staff had enrolled on or had completed national care qualifications. Other training was also available. The staff members we spoke with felt the training they were receiving provided them with the skills and knowledge to support people well.