Mayflower Care Home

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 outstanding. At this assessment the rating has changed to 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 regulation in relation to governance at the service.

This service scored 62 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Information about the vision, strategy and culture was available around the service for people, relatives, visitors and staff. The provider and management team were passionate about the service and wanted to ensure people had good quality care and improved outcomes. The provider had told CQC through the submission of their provider information return (this is information CQC request from providers on an annual basis) about workforce equality, diversity and inclusion. They stated,

‘All staff at Mayflower Care Home are committed to ensuring that equality and diversity is at the heart of all we do. This means ensuring that Human Rights principles are embedded in the delivery of our services and an inclusive and working environment is always fostered. It also means ensuring that our staff are treated equally, listened to, valued as individuals, and given the same opportunities to progress in their careers regardless of their race, age, gender, sexuality, disability, culture, or anything else that might be discriminated against so that each member of staff can reach their full potential and develop new skills.’

Staff gave positive feedback about the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions. Comments included, “I’d like to think there is a good culture, staff are there for the residents”; “There is a good culture in the service, we have a pretty good team” and “I feel confident to go to the managers. [Registered manager] was an amazing manager. There is a good culture, everyone gets on and works together.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The management team knew people well and were passionate about making sure people received good quality care. Staff understood their responsibilities to meet regulatory requirements. The registered manager (who was in post during our site visits but left the service on 28 November 2025) was supported by the regional director for the provider. The provider had put an interim manager in post at the service until the vacant registered manager position could be filled. The interim manager started in post on 24 November 2025 to ensure they worked alongside the registered manager for a week to gain a handover and get to know people and staff. Some staff raised some concerns about the attitude of a staff member towards them, we discussed this with the management team during feedback and received assurances that actions had been taken to address the concerns and a process of coaching and mentoring was put in place.

Services providing health and social care to people are required to inform the CQC of important events that happen in the service. This is so we can check that appropriate action has been taken. We were assured that incidents had been appropriately reported.

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

Staff confirmed they were invited to meetings and encouraged to contribute. Staff meeting minutes evidenced that these took place regularly. Staff told us they were encouraged to voice their ideas for improvements and any concerns. Staff said, “We have a weekly clinical risk meeting”; “We report issues if we are worried. There are monthly staff meetings, clinical meetings and daily flash meetings” and “We always discuss in meetings what could have been done differently when it comes to incidents.” Staff knew how to raise concerns with the provider or outside organisations if they needed to.

Complaints processes were available. Relatives told us concerns and complaints were listened to. They said, “I raised a concern about some medication and they helped me understand by being in a meeting with the mental health team” and “I felt dad needed an increase to his medication. They listened to me, and it was increased.” Relatives knew who the registered manager was and were positive about the access to the management team, nurses and staff in general. They told us staff were approachable, mostly responsive and accessible and had followed up any concerns or issues they had. A relative said, “I know the manager and we are sad she is leaving. She is hands on and has created a nice atmosphere in the home.”

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 processes in place to encourage an inclusive culture. The workforce was diverse, and support was in place for staff. The registered manager had an open-door policy. Staff told us about the support they had been given in their roles. Staff had completed surveys in late 2025 and the provider had analysed the results. The provider was keen to improve staff experiences at work. Despite the provider having an employee assistance programme and staff recognition systems. Some staff had said in their surveys that they were not fully aware of the things available to them. The provider had put an action plan was in place because the survey results showed staff awareness of the employee assistance programme was too low, recognition was not consistent for all staff, staffing levels and shift issues had appeared, there was some mixed feedback on leadership consistency and communication could be improved, especially regarding wellbeing support.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes in a timely manner. The provider had systems in place to check the quality of the service. Audits had been carried out. There were monthly audits of infection control, care plans, medicines, call bells, falls and wounds, MUST (malnutrition universal screening tool), incidents and accidents, oral health, mattresses, health and safety, and fire. We saw that actions had been completed to address most issues identified in the range of audits. However, audits had not picked up the issues we identified in the site visit with risk management, infection prevention and control, environment and medicines. Actions from audits had not always taken place in a timely manner. For example, the maintenance team identified on 3 September 2025 a long list of damaged beds, these had not yet been replaced. Records at the service identified that a person had injured themselves on one of the damaged beds in October 2025. The management team confirmed this person’s bed was changed the same day of the incident. Whilst this mitigated the risk of further harm to the person, the provider had not reviewed the timeliness of actions to replace the other beds. The provider had utilised management consultants to carry out independent audits and checks of the service. We reviewed the consultants report and noted that they too had reported these damaged beds in late September 2025. The registered manager told us these beds were being ordered at a rate of 10 per month but only 5 had been replaced out of 57 at the time of our assessment. This meant 52 beds remained a risk to people at the service.

The provider’s maintenance checks in April and May 2025 identified issues with fire doors. At the time of the assessment action had still not been taken to address the concerns. The management team confirmed this work was still pending as planned works with the provider’s estates team. The management team told us after the assessment that a local contractor had carried out immediate remedial works to fire doors in October 2025. They informed us since the assessment 'Priority remediation works have been formally instructed, with completion expected by March 2026.This structured approach enables a focused and proportionate response, including identifying any door sets requiring full replacement. Where replacement is indicated, works are scheduled to commence from April 2026.'

People's personal records were stored securely including on computers and applications on devices, these were protected by passwords, so that only staff who had been authorised to access the information could do so. Staff said most of the management team were supportive and approachable. The provider had displayed their last inspection rating on their website and within the building.

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 management team and staff worked hard to build and maintain relationships with health professionals, working in collaboration with other services to ensure good, joined up care for people. The service had developed partnerships with varied organisations and the local community through activities, end of life care, the local authority and through good links with GPs. The service held a community dementia café once a month for the local community and offered hot desking opportunities for professionals.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice and research.

The provider had a system in place to monitor the quality of the service. The audits had identified shortfalls, the service had been placed into the provider’s improvement programme, and an action plan was in place. The management team had signed off areas to confirm they had been completed. However, further shortfalls had been identified at this assessment, the quality of the service had deteriorated since our last assessment. Since the site visit there had been some learning as measures had been put in place. The management team confirmed with us they were taking action to address issues found. The regional director told us that the provider was taking the damaged beds situation seriously and had asked to ramp up the replacement to more than 10 beds per month.

The service was looking to improve to further develop support to people living with dementia, such as creating sensory spaces at the ends of corridors. When a visit was undertaken by the Alzheimer’s Society, they made some suggestions to further improve the lives of people living with dementia such as changing the colours of handrails in corridors on the ground floor to a different colour from the walls. They identified that toilets had white seats and recommended to change these to blue. They also identified an upstairs lounge had 3 different types of flooring which they advised could be disorientating for people living with dementia. These changes had not yet happened and were being planned for 2026.