Mayfield Road

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 as good. 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.

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 culture which was based on transparency and engagement. The provider had a shared vision for the service which was originally shared with staff during their induction into the organisation, and thereafter through supervisions and team meetings. However, due to the lack of stable management, the provider had been unable to successfully implement their vision. We were provided with a copy of the provider’s mission statement and organisational strategy, which was shared with staff. Staff told us the vision and values were shared with them during their induction and thereafter, but they also said their morale had been affected by the recent management changes and ensuing lack of stability.

Staff confirmed they were given the company handbook that included relevant information about the organisation and their values. The acting manager told us “The values are part of team meetings, reinforced through training and in 1:1s.”

Not all leaders understood the context in which the provider delivered care and support. Leaders did not always have the knowledge and experience to lead effectively. During our assessment of this service there was no permanent manager in post. At the beginning of the assessment process, the provider had commissioned one person to lead the service for a short- term contracted period. Thereafter, another person had been appointed to lead the service.

Staff told us there had been no permanent leader in post for some time due to the multiple leaders leaving their posts within a short period of time. They told us they found this destabilising. One staff member told us “Obviously it’s been a difficult time, but things are improving now.”

People’s relatives also told us they found the lack of permanent leadership in the home had created problems. One relative told us they were “concerned about the management situation” and felt they had not received enough communication about this.

We spoke with senior staff at the service about this issue. They confirmed a new manager had been hired and was due to start at the service in January 2026.

People did not always feel they could speak up and that their voice would be heard. Both staff and relatives gave mixed feedback about whether they felt they were listened to. They told us they felt the lack of a permanent manager had created a difficult working situation and in turn they felt they were not being listened to. We spoke with the acting manager about this and they confirmed that they were working to address this by scheduling supervision meeting with staff as soon as possible.

There was a grievance and whistleblowing policy in place as well as a helpline for staff to contact if they felt unable to speak to their immediate manager.

The provider valued diversity in their workforce. The provider employed a multicultural workforce and reinforced the importance of respect and tolerance for others. All staff had completed equality and diversity training and told us they felt their diversity was respected. One care worker told us “I do feel like I’m working for an inclusive organisation.”

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

Due to the lack of a permanent manager in post, there was a lack of leadership within the service. Staff had a good understanding of their roles and responsibilities, which were made clear to them when they applied for their roles. However, the lack of management had created issues. One care worker told us “It’s been a tough time, but things are getting better.”

The provider did not always act promptly on the best information about risk, performance and outcomes. We identified one person whose needs had increased and this information was not shared promptly with others. The provider confirmed they had eventually sought external support for the care of this person following our site visit.

This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. One local authority told us they were concerned the provider had been slow to act in relation to the needs of one person. Although the provider had since sought external support for the care of this person, they remained concerned about the provider’s ability to act promptly in relation to people’s needs in light of the lack of permanent manager in post. We spoke with senior staff about this and they confirmed they were providing senior support to staff within the service to ensure there were no other issues in relation to people’s care and they had hired a permanent manager.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. The provider audited different areas of the service. This included weekly medication audits as well as quarterly record- keeping and governance audits among others. When issues were identified, action plans were put in place to resolve issues.

We saw accidents and incidents were also dealt with individually. However, there was no system of review of accidents and incidents to monitor trends or learn lessons from incidents to improve the service overall.