Mayflower Court

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 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 requires improvement. At this assessment the rating has remained requires improvement. The provider was in breach of legal regulation in relation to the governance of the service.

This service scored 57 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The provider had a clear aim of providing a caring person-centred service which promoted people’s rights. However, we did not always observe this. For example, we saw in several parts of the service some staff were focused on the tasks such as tidying and providing drinks, whilst missing the opportunity to chat and interact with people.

Whilst we found leaders at all levels were visible within the service and they led by example, we found they had not always identified issues we found during this assessment. There had been changes and inconsistent management at service level for approximately 4 months prior to this assessment. A temporary manager and new deputy manager had been appointed and were supported by an area management team. Where we identified areas for improvement the management team were receptive to our findings and where possible took prompt action.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The provider had mechanisms in place for people, family members and staff to give feedback. Where feedback was sought via surveys, this was analysed for patterns and trends. All staff said they felt able to raise anything with the management team and felt they would be listened to. There was no evidence of closed cultures.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. There was an open and inclusive recruitment procedure. The management team described how they recruited staff based on their compassionate natures, skills and experience. Care staff were positive about working at Mayflower Court and would recommend it as a place to work.

The provider did not have effective systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Systems and processes in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of people had not identified areas for improvement detailed in other sections of this report which we found during this assessment. We found improvements were needed to ensure individual risks for people were identified and action taken to mitigate risks, concerns with medicines management and risks relating to the home’s environment. The management team were receptive to our findings and undertook to make improvements.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The management team expressed an open positive attitude to receiving support and understood how and where they could access support. They were developing close links with various local health and community organisations including schools, social activities and religious organisations.

The provider did not always focus on continuous learning and improvement across the organisation and local system. They did not always actively contribute to safe and effective practice. The management team were open to feedback provided and undertook action to address immediate concerns we raised. However, some of these issues had previously been identified in internal audits and action had not been taken. Where action had been taken this had not always been embedded and migrated to other areas of the service.