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Inspection Summary

Overall summary & rating


Updated 21 February 2018

The inspection took place on the 29 and 30 January 2018 and was announced. The location was previously inspected in June 2016. It was not in breach of any regulations of the Health and Social Care Act 2008 at that time, however they received an overall requires improvement rating. This was a comprehensive inspection to review the progress made and rating since the previous inspection.

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats in the community. It provides a service to adults. At the time of the inspection they were providing a care package to 180 people whose contract of care was sub- contracted to them from another two agencies.

Not everyone using Mayfair receives regulated activity; CQC only inspects the service being received by people provided with ‘personal care’; help with tasks related to personal hygiene and eating. Where they do we also take into account any wider social care provided.

The agency had a registered manager. 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 previous inspection in June 2016 the service was rated as requires improvement in all domains, with an overall requires improvement rating. At this inspection we found the service provided safe, effective, caring and responsive care. The service had a committed registered manager who had made the improvements to the service. However, the lack of an electronic logging in and out system meant there was a delay in auditing if all of the care calls had been provided which has resulted in a requires improvement rating for well- led.

Staff schedules were planned in geographical areas to cut down on travel time between calls and in an attempt to reduce delays between calls. The registered manager and staff from the agency felt confident no calls were missed. However, records were not always completed to support this and some people told us they had experienced missed calls.

People were asked for feedback on the service to improve practice. The registered manager and the provider audited the service to satisfy themselves the service was running effectively. However, the task of manually auditing communication sheets for the previous month meant that gaps in care calls were not highlighted and brought to their attention in a timely manner to ensure people got the care calls they required.

Some people were happy with the care provided. They had positive relationships with staff and described staff as kind, caring, excellent, helpful and accommodating. One person described staff as like friends to them. Other people told us that the times and reliability of the calls could improve.

Systems were in place to safeguard people. Risks to people were identified and managed. People were assessed prior to the package of care commencing. They had support plans in place which outlined the support required at each call. The support plans were updated and reviewed in response to people’s changing needs.

Medicines were safely managed with people supported and enabled to self-medicate where possible. Staff were clear of their responsibilities in relation to medicine administration.

People’s privacy and dignity was promoted. Staff were respectful of the person’s home and their environment.

Staff were suitably recruited, inducted, trained, supervised and supported. This enabled them to have the right skills and training to support people effectively. Staff felt they worked well together as a team to ensure people got their required care calls.

People and their relatives knew how to raise concerns. They confirmed the registered manager was responsive to issues raised by them to offer a reso

Inspection areas



Updated 21 February 2018

The service was safe.

People were safeguarded and risks to them were identified and managed.

People were provided with staff, although not always at the times agreed to meet their needs.

People’s medicines were appropriately managed.



Updated 21 February 2018

The service was effective.

People were supported by staff who were inducted, trained, supervised and supported.

People were supported and enabled to make decisions about their day to day care within the principles of the Mental Capacity Act 2005.



Updated 21 February 2018

The service was caring.

People were supported by staff who were kind and caring.

People’s privacy, dignity, independence and respect was promoted.



Updated 21 February 2018

The service was responsive.

People had support plans in place which outlined the care required at each call.

People were provided with information on how to raise a concern or complaint.


Requires improvement

Updated 21 February 2018

The service was not always well-led.

People’s records were not suitably maintained in that some communication logs were not completed to confirm if people had received their care call.

People were given the opportunity to feedback on the service. Systems were in place to monitor practices to safeguard people and make improvements to the service. However a robust system was not in place to audit that care calls had taken place in a timely manner.

People were supported by a registered manager who was committed to bringing about improvements to the service.