Mayflower Care Home

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• 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 remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to staffing, a continued breach of management of risk, and infection control and premises and equipment.

This service scored 53 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. The registered manager completed a monthly review of the service which included learning points. Analysis had been carried out by the management team to determine the root cause of incidents and actions were taken to prevent things happening again. For example, the registered manager had discussed with staff themes regarding falls, accidents and incidents. Staff had highlighted the higher incidents of falls happened at weekends and they identified this could be because more agency staff were used at weekends. The management plan for the service included reducing agency use.

A staff member told us, “We have group discussions and talk through lessons learned, there are processes in place. It would be discussed in flash meetings.”

Records showed that relatives had been contacted when there had been incidents and accidents and actions had been taken. A relative said, “They notify me if he has a fall.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. The provider had an electronic care planning system. This enabled the staff team to create hospital passports when these were needed. A hospital passport helps people to give hospital staff and other services important information about them and their health when they go to hospital.

People were supported to maintain their health and attend appointments, both inside and outside of the service. Where routine health checks were undertaken people had support from staff who they know well to understand what was happening.

The service had maintained regular contact with local authority social workers. This included ongoing work with the GP and other health and social care professionals. Staff told us they were able to contact the GP. We observed a community nurse visiting the service to provide additional support and advice to the nursing staff about a person’s wound. The home visiting team from the GP surgery also visited the service as part of their weekly ward round. A staff member told us, “I do call 111, the GP and the advanced nurse practitioner.”

A relative said, “He sees the GP, and we support him to make any appoints as needed.” Another relative told us, “With the GP - they manage that and I’m happy with that.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were safe and were protected from harm. Safeguarding policies included information about safeguarding children from abuse. Safeguarding training included safeguarding children. This is because staff in care services come into contact with children as part of their work. The management team had reviewed processes and learnt lessons from safeguarding incidents. We observed interactions between staff and people during our visits. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Staff had received safeguarding training. Staff understood their responsibilities to report a safeguarding concern. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. Staff told us they were confident to speak up if needed. A staff member said, “I would document abuse, report it to the manager and senior, make sure the person is ok. It would 100% be dealt with. I could report it to CQC.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. DoLS applications and authorisations were in place for people around any restrictions within their lives that they did not have capacity to consent to. Systems to review these were also in place.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risks to people in relation to possible harm from constipation were not always well managed. For example, action had not always been taken to give people as and when required laxative medicine according to their care plan. Risk assessments and care plans lacked information about what was normal for them and what staff should do if they had not had their bowels open for a set amount of time (such as 48 hours or 3 days) We found a case where a person had not opened their bowels for 5 days, and no action had been taken. Another person had only opened their bowels 5 times in 25 days. We reported this to the management team and actions were taken to address people’s constipation and possible discomfort.

Risk assessments were inconsistent. For example, some were detailed and provided clear guidance to staff about how to work with people safely. Others were vague and did not give clear guidance. For example, people’s epilepsy risk assessments had not fully explored the risks and actions to mitigate risks such as SUDEP (Sudden Unexpected Death in Epilepsy) and choking. A person’s skin integrity risk assessment showed that their pressure relieving mattress should be set at a particular setting to meet their assessed need. We checked and the mattress was not at the correct setting. We reported this to a member of the nursing staff who took action to change the mattress to the correct setting. We observed that people were not always repositioned in accordance with their care plans. People’s emotional support care plans and risk assessments did not always provide guidance for staff on what action they should take to support people when they became anxious and distressed.

A person told us, “The staff take care of me and make me feel safe.” Staff had a good awareness of people’s choking risks, and we saw them supporting people to sit up more to eat and drink. People were given food and fluid in a consistency which was in accordance with their assessed needs (including diabetic diets). The food was well presented, and people seemed to be enjoying the experience.

Personal emergency evacuation plans (PEEPs) were in place in the service to detail people’s support needs if they required to be evacuated in an emergency. People were supported to move around the service safely and were supported to spend time where they chose. Staff told us about safe ways of working with people which demonstrated they knew them well.

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

Records showed that a large number of beds required replacing due to damage which had potential to cause injury. The maintenance team had identified this in early September 2025, management consultants who carried out an audit also raised this in late September 2025. Replacement of these beds had been added to the provider’s improvement plan. In October a person sustained an injury from one of the damaged beds. The registered manager had escalated the beds concerns again to the provider and took immediate action to replace the person’s bed. Within the incident record relating to the injury – it was recorded that there were 57 beds in total that required replacement, which posed a risk to people. The management team advised us the issue was being taken seriously. A relative told us, “I would like [person] to have a new bed as this one is all chipped and unhygienic. I have offered to buy one, but they said they would sort it, but nothing has happened.”

Other maintenance tasks appeared to have been completed in a timely manner. Rooms were tidy and had been personalised in accordance with the person’s wishes. A redecoration programme was in place, some rooms had yet to be completed. Fire exits were clearly visible and unobstructed. The lift was clean and in working order.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They made 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 had regular supervision meetings, induction was a mixture of training and shadowing experienced staff to gain confidence and experience. The training matrix showed that most staff had completed mandatory training. However, the training records showed that staff had not completed additional training to meet people’s assessed needs, such as Parkinson’s disease training, epilepsy training (despite a number of people living at the service with epilepsy and Parkinson’s disease). Some staff did not have any experience of working with people with epilepsy. Whilst we had not identified any direct impact to people in relation to this, risks of not meeting people’s needs safely were identified. Staff told us “I did epilepsy training within my nursing training but not completed a course on epilepsy. I think most staff would recognise there’s something wrong with a person and would report it to the nurses, they might not recognise the person was having a seizure but would recognise they are not their usual self. There is no Parkinson’s training, as nurses we have access to the nursing times for guidance”; “I have witnessed residents having seizures, I press the call bell, put them in the recovery position if I can and the nurse will take over. They would call the doctor if the person was having more seizures than usual” and “I might have done epilepsy training, I did first aid. I would call the nurse if someone was having a seizure.” Most staff had completed autism training; however housekeeping staff had not. The management team told us after the assessment site visits that they had added additional training for staff to complete. They also planned for staff to complete some training in sign language to help staff communicate with people who used sign language. The management team told us that basic emergency first aid at work training covered seizures which supported safe practice.

We observed call bells were answered quickly. A person told us there was enough staff. Relatives told us, “Yes, there seems to be [enough staff] from what we see. They look after him well”; “Sometimes there could be more staff, but there is no pattern as to when that is. I don’t feel it impacts care” and “There are more staff in the day than at night. I feel that’s ok.”

Staff gave us mixed feedback about the staffing levels. Comments included, “There’s not enough staff on shift on diamond, only 3 staff on shift, they reduced it as there are 5 empty beds. However, some of the empty beds were people what were quite independent and did not need a lot of support. I have not fed this back to management, but staff have been talking about it amongst ourselves. The whole shift it is like it, it’s quite hectic”; “The bottom floor sometimes only has 2 carers and 2 seniors, yesterday there was just 4 carers and me on the diamond unit, I don’t think there is anyone that is not a double handed for personal care. One staff member is always in the lounge, which leaves the 2 other carers to do all the personal care for the whole floor. We have to prioritise people and people have to wait for their personal care. It is stressful”; “I do think there is enough staff” and “It varies it we have enough staff, sometimes staff are moved to another unit to cover sickness, when this happens the senior then goes on to the floor to back fill but they have to do the senior work still.”

Staff had been safely recruited. All required checks had been carried out, and documents were all in-date. The information helps employers make safer recruitment decisions. Nurses were registered with the Nursing and Midwifery Council. The provider had made checks on their personal identification number, registration status and renewal date.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. Some areas of the service required deep cleaning to control infection risks. There was a smell of stale urine in places. Damaged beds (which we reported about in the safe environments section of the report) presented an infection control risk as they could not be cleaned effectively. However, infection control concerns that had taken place had been shared with appropriate agencies promptly.

The provider had a daily cleaning programme in place. The service employed housekeeping staff to carry out daily cleaning. Cleaning schedules were in place which included deep cleans for people’s rooms. Infection control audits were completed regularly and actions taken if any issues were found. Relatives told us, “I believe there is a cleaner the home is always clean and tidy”; “The home is always clean and tidy when I visit” and “You know when the cleaner has been in as it smells lovely and fresh, they are kept busy as the residents walk around spilling things all the time.”

The provider had plenty of PPE (Personal protective equipment) in place to keep people and staff safe. The kitchen areas were clean and well managed. We observed that the staff were using PPE effectively and safely.

Staff told us they had sufficient equipment and PPE to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks. Staff said, “There is enough PPE, it is kept in cupboards with locks” and “There is plenty of PPE, gloves are always available as well as aprons and wipes. Masks are available when needed.”

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We were not able to reconcile medicines stock with prescribing and it was not possible for us or the management team to identify if medicines had been given as prescribed for everyone as there were a number of inconsistencies in relation to medicines counts. PRN (as and when required) laxatives had not always been identified as required on the MAR (medicines administration record) charts for people who had not opened their bowels. Staff had not always identified that people had not opened their bowels and had not offered or administered PRN laxatives or natural remedies in a timely manner.

Medicines were securely stored and timed medicines were given appropriately. The ordering process for prescribed medicine was effective. The management team carried out regular medicine audits. An audit had taken place on the night of 24 November 2025, but it had not highlighted the issues we found with stock on 25 November 2025. The clinical lead carried out regular medicines audits too. Following our findings, the management team advised they would complete more regular stock counts to reduce the risk of stock issues. The nursing staff and management team said that sometimes the electronic MAR (EMAR) system did not sync properly. When this happened they reported these issues to the EMAR provider, they had embedded changes to recording because of this issue. Staff also recorded in each person’s daily care notes when medicines had been administered.

People and their relatives told us they received their medicines when they needed them. Comments included, “I'm not on a lot of medication, mainly pain killers”; “She is being assessed at the moment for her medication, but the staff sort all of that out for her”; “They deal with all his medications and keep us informed of any changes”; “The staff here deal with all his medications” and “We can check on the portal to see if she has taken them, they sometimes have to give her Lorazepam if she becomes anxious, but they don't like to give her too much as they want to make sure she is alert enough to experience moments of joy.”