Mayfield Road

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 as good. At this assessment the rating has changed to 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.

This service scored 59 (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 encouraged a culture where staff discussed and learnt from things that went wrong. Staff reported and recorded accidents, incidents and concerns. These were investigated in accordance with the provider’s incident management policy and procedure and appropriate action was taken to keep people safe. Managers discussed lessons learnt from individual incidents in staff meetings to ensure staff were aware of risks. Appropriate records were kept, so lessons were learned and trends were monitored.

The provider supported people to have safe transitions and pathways. 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, when people were moving between services. People’s care records included information from other professionals to ensure care was joined up.

The acting manager confirmed they worked with other partners to ensure there was continuity in the management of people’s care. Where people were moving between the hospital and the home, the provider ensured each person was accompanied by a staff member along with a hospital passport to ensure information was shared.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider did not always share concerns quickly and appropriately. For example, we identified an instance where the local authority confirmed the provider had been “slow to act” in responding to the needs of one person. We spoke with the provider about this and they agreed they had not been proactive enough in managing the situation and seeking support. They promptly sought further support after our site visit after conducting a review.

People and their relatives gave mixed feedback about whether they felt safe using the service. One relative commented “I feel my [family member] is safe with them and they provide good care”. Another relative told us they did not think their family member was safe with staff.

Staff received annual safeguarding training and appeared to understand the signs of abuse. However, with regard to the person identified, they agreed they needed to learn lessons about how to respond more promptly to their needs.

The provider had clear safeguarding processes in place, which were outlined in a safeguarding policy and procedure.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care that was supporting people and met their needs. We identified one person whose needs were not being sufficiently met. Although their care plan was clearly written and included detailed risk management guidelines, these were not sufficient to ensure the person’s needs were met and appropriate action was not taken to review the risk management guidelines in light of this. We found the provider was not taking action quickly enough to identify and support the person with their issues or to seek the further support that was needed in the management of their care. The provider confirmed they had sought further support in relation to the person and they were subject to an ongoing review with the relevant local authority.

Staff had a good understanding about the risks to people’s care and gave us examples of individual people they provided care to. Staff had received training in the management of people’s needs, but some staff appeared overwhelmed in the management of one person’s care and stated they required further guidance in how to support them effectively. The provider confirmed they were working with external partners to seek further support in the management of this person’s care, which they would share with staff as soon as possible.

The provider did not always make sure equipment supported the delivery of safe care. On the day of our site visit, we identified a number of chairs in the dining area that were broken. The provider ensured these were immediately removed and were later replaced.

There were clear environmental risk assessments conducted that included areas of risk both inside and outside the premises. Where issues were identified, these were followed up and actions were taken to remedy these.

The provider ensured equipment such as slings and hoists were checked regularly and replaced where necessary. They conducted regular health and safety audits to ensure the home was safe, but these had not identified the issues with the dining room chairs. The acting manager confirmed they would review these systems to make sure they identified issues going forward.

The provider did not always make sure there were enough suitably skilled and experienced staff supporting people. 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.

The provider confirmed they carried out monthly supervisions with staff and provided us with examples of supervision forms that recorded discussions they were having with people. Staff told us they had received supervisions and appraisals and found them useful. However, records indicated that although staff received monthly supervisions they had not had any for four months from July 2025 due to the lack of stable management within the service. The acting manager told us supervisions were a priority and they were in the process of arranging these.

Staff had not always received training that was sufficient to support people with their individual needs. One person who presented with complex care needs had a particular health condition that required staff to receive specific training, but staff did not feel able to manage their care needs. We also identified that only 66% of staff had received Tier 2 Oliver McGowan training. The Oliver McGowan Mandatory Training isa mandatory training program for the health and social care professionals in England, focused on learning disability and autism. The training is delivered in two tiers. The first tier is a foundational online course for all staff and the second tier is a more in-depth face-to-face session for those who require it. We spoke with the acting manager who confirmed up to date training was being arranged for staff in the person’s care needs as well as Oliver McGowan level 2 training.

This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Staff told us they felt there were enough of them on shift to support people and rotas demonstrated this.

We observed there appeared to be enough staff working during our site visit. We observed people’s requests were responded to quickly.

The provider assessed and managed the risk of infection. There was a clear infection control policy and procedure in place.

Staff had received infection control training and had a good understanding about their responsibilities. They confirmed they were given the equipment they needed to maintain good infection control.

We observed staff wearing PPE where necessary and people had individual slings for their use where needed. The environment appeared clean during our visit and there were clear cleaning protocols in place to ensure the premises were hygienic.

The provider ensured medicines were given safely and met people’s needs.

We saw medicines records were stored securely and were accurately filled in, but old Medicines Administration Records (“MARs”) were stored with current ones. This made current records difficult to find. The acting manager ensured medicines paperwork was reorganised after our visit.

There were clear medicines care plans in place and these included details of what medicines people were required to take. Medicines records were audited on a monthly basis. PRN protocols were in place and we saw these administered safely.

Medicines were stored securely, but not always in line with requirements. We saw that some medicines were stored with Controlled Drugs (“CDs”) despite not being CDs. The acting manager confirmed this was a misunderstanding by staff as to what constituted a CD and they said they would address this with them. We also saw a large number of old medicines that required returning to the pharmacy. We were told by the deputy manager that these were returned to the pharmacy once a month and the acting manager confirmed after visit that this had been done.

Staff received annual training in medicines administration and had their competencies checked. There was a medicines administration policy and procedure in place.