Mayflower Court

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 good. At this assessment the rating has changed to requires improvement. This meant people were not always safe and protected from avoidable harm. The provider was in breach of the legal regulations relating to the safe assessment and management of risk to people, the environment and the management of medicines.

This service scored 56 (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 proactive and positive culture of safety, based on openness and honesty. Safety events such as accidents and incidents had been investigated and reported with actions taken to mitigate against reoccurrence. Duty of candour, which requires providers to be open when things have gone wrong, was followed where necessary. Family members and staff confirmed they were updated following accidents or incidents.

The management team worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services. Systems were in place to ensure continuity of care when people commenced a care service which included involvement of the person, family members and external health or social care professionals. The electronic care planning system enabled staff to produce an information pack if a person needed to be admitted to hospital or transferred to another service. This helped to ensure the smooth transfer of their care.

The management team worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Appropriate action had been taken in response to safeguarding concerns, however, some staff were unsure about the extent of their safeguarding responsibilities and described actions they would take if a concern was raised to them. The management team agreed to undertake further training with staff to ensure they knew the extent of actions they should take if a safeguarding concern was raised to them. People and their family members told us they felt safe at Mayflower Court.

The provider did not always work well with people to understand and manage risks. Staff did not always have the information they needed to ensure care was provided which met people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Risk assessments were not always in place, updated when needs changed or sufficiently detailed to ensure people’s needs could be safely met and managed. We identified additional information was required in relation to diabetes risk assessments, epilepsy, risks relating to food and drink, and mobility. The management team undertook to review risk assessments and care plans to ensure information about people’s individual risks and how these should be minimised was consistent, accurate and up to date.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment and facilities supported the delivery of safe care. We found where risks had been identified from internal and external audits, these had not always been acted upon. Some routine monitoring of environmental risks was not being undertaken appropriately. This meant people were at risk of harm. Once we identified these concerns the management team assured us action would be taken. Mayflower Court supported some people living with dementia. An audit of the home’s environment to determine if improvements could be made to better support people living with dementia had not been completed.

The provider did not always make sure there were enough qualified, skilled and experienced staff available to meet people’s needs. Most people or their family members felt there were usually sufficient staff. People told us, “Sometimes at weekends there doesn’t seem to be many carers around” and “Most of the time there are enough staff, but at weekends or if there’s been a crisis you need extra staff to deal with it”. These views were also reflected by a visiting health professional who told us they could not always find staff to support them. We identified that at busy times such as mealtimes, there were not always enough staff in each area of the home to support people with their meals and other needs. The management team undertook to review staffing allocations and introduce a ‘protected mealtime’ to help ensure sufficient staff were available to support people. Staff received effective support, training, supervision and development.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had received food hygiene and infection control training. Staff confirmed the availability of personal protective equipment (PPE) which we saw them using where needed. The home appeared clean, although some areas were in need of refurbishment to support effective cleaning.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found prescribed topical creams for personal care and fluid thickeners were not stored securely. Once opened some prescribed medicines and topical creams have an in-use expiry date. Generally, the date these were opened and a use by date were added to packaging, however, the expiry dates were not always consistent with the manufacturer’s recommendations. This meant people may be at risk from receiving prescribed medication that was no longer safe to use. The provider had identified in a recent audit individual ‘when required’ guidance was not in place for all medicines and the quality of those in place was variable. This meant people may not receive as required medicines in a safe and consistent way. Care plans did not always include prescribed ‘when required’ medicines. This meant staff or other professionals may not be aware of these, or of when they should be administered and people may not receive these when they needed them.