4 July 2022
During an inspection looking at part of the service
Mayfair Residential Care Home Ltd is a care home providing personal care to up to 20 older people, some of whom may be living with dementia. At the time of this inspection, 13 people were living at the service.
People’s experience of using this service and what we found
The service was not safe. Risks to people had not been assessed or recorded. Checks of equipment, maintenance checks and servicing had not been completed at required intervals. Where shortfalls had been found in relation to the health and safety of the service, action had not been taken to address this.
Medicines had not been administered or managed in a safe way. Safeguarding concerns had not been appropriately reported and thorough recruitment checks had not been completed prior to new staff commencing employment.
Staffing levels were not always sufficient which impacted on the quality of care provided. Staff had not been provided with sufficient support or training to ensure they had the skills and knowledge to carry out their roles.
Action had not always been taken to seek professional’s advice and support when people had lost weight or suffered a high number of falls. People’s care plans had not been updated to reflect people’s current needs, and end of life care plans only contained basic information. We have made a recommendation about end of life care planning.
There was a lack of activities and stimulation within the service. We have made a recommendation about activities. People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice
There was a significant lack of provider oversight and leadership within the service. Quality assurance processes were either not in place or had not been completed for a considerable amount of time. The provider had failed to take action to ensure they were meeting regulatory requirements.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was requires improvement (published 8 April 2020) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.
Why we inspected
The inspection was prompted in part due to concerns received about the lack of management oversight within the service. A decision was made for us to inspect and examine those risks.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this full report.
The provider acknowledged the significant shortfalls found during this inspection. They took action following the inspection to begin to address some of the shortfalls found. They produced an action plan and began to work with the local authority to make improvements.
The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mayfair Residential Care Home Ltd on our website at www.cqc.org.uk.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to health and safety, assessing and managing risks, infection control, medicine management, recruitment processes, safeguarding people, nutritional needs, staff support and governance at this inspection.
You can see what enforcement action we took at the end of this report.
Follow up
We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.
The overall rating for this service is ‘Inadequate’ and the service is therefore special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.