Mayfield Road

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• 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

We assessed all the quality statements within this key question. Our rating for this question has improved to Good. Since our last assessment a new registered manager and deputy manager had been appointed. There was stronger leadership and oversight at the service. A new governance structure had been introduced across the provider group which enabled closer review of quality of service delivery and the sharing of outcomes across the provider’s services. There was a commitment to continuous improvement and the team was working hard to continue to improve the service and outcomes for people.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team understood the provider’s vision and values and how to apply them. There was an open culture at the service aimed at encouraging staff to be involved and share their views with the provider. The registered manager told us their work included, “Celebrating the small positives, praising openly, being visible and communicating openly and honestly. We encourage freedom to speak up.” The service apologised to people, and those important to them, when things went wrong. 

The provider brand, Active Care Group, had a clear direction based on quality evidence-based care. The management team at the service were working with the staff group to develop a positive culture, that was in line with the provider’s vision and values.

Managers worked together with the staff team to develop and improve service delivery. Staff’s comments included, “Now it is better and everything has improved since last year. We still have work to do as we have new staff. But we have staff and they are willing to learn. Before we used a lot of agency and they would not care about the residents. We are now on the right track” and “It's good, of course the managers are very supportive. They listen and are always available when you want to talk to them or discuss something.” The registered manager told us, “I want staff to tell me what is wrong. I want to hear if staff disagree with me.”

The leadership team at the service had been strengthened. A new registered manager was in post and the team had been further strengthened with the establishment of a deputy manager post. There were clear management and reporting structures in place.

Staff were aware of the whistleblowing policy and the actions they had to take should the provider not respond to the concerns being raised about people’s care. Staff were confident the registered manager would respond appropriately if a concern was reported to them. Staff’s comments included, “I would talk to the manager first and call the head office. They would definitely do something. I would go to council and police if they don’t do anything” and “I would go to the CQC if the entire organisation is not responding.” The registered manager told us, “Openness and transparency is important and admitting when the manager gets it wrong. It encourages the staff team to be open also.”

A whistleblowing policy was in place and staff were supported to speak up.

Staff’s commitment was important to the provider. Staff were motivated in their roles to drive performance. This included staff being nominated and awarded for their achievements.

Systems were in place to ensure staff had access to the same equality and diversity rights as the people using the service and ensure their individual needs were taking into account and supported.

Staff members who were confident and competent to do so, were given additional responsibilities in their roles and learnt new skills. They were booked to attend manual handling and fire safety training courses to take on a lead role in these areas. The registered manager told us, “I think you get the best out of people enabling them to do more of what they are good at.”

Governance processes had been restructured and strengthened. There was now greater oversight on quality and greater sharing of learning across services. Regular local and regional governance meetings were held, where outcomes of audits and key performance data were reviewed.

There was good leadership at the service. Family members told us the registered manager was committed and approachable when needed. Comments included, “There’s a new manager now and she seems to be making the right moves. We are optimistic. She does respond, she doesn’t ignore anything”, “We meet the [registered] manager all the time. I email her every day. She says- ‘keep telling me what the problems are which is very good”, “[The registered manager] offers constant reassurance, and is very receptive” and “[The registered manager] is brilliant, can’t fault her at all. She’s excellent. She knows her job that’s for sure. Since she’s taken over there’s been big changes.”

The service engaged in working with other organisations to support people using the service. This included partnership working with health and social care professionals such as GPs and Local Authorities. The service also aimed to expand their relationships in the community introducing new activities for people such as pet visits at the home.

Partner agencies told us they worked well with the registered manager. They said the registered manager was open to feedback and they had seen a number of improvements at the service.

The provider was strengthening their relationships and processes with partner agencies, and rebuilding connections to ensure people received coordinated care. Processes were in place to obtain feedback from people and relatives. Relatives’ meetings had been reestablished and the management team was also meeting with relatives individually to discuss care and service delivery.

There was a good management structure in place with shared responsibilities to oversee the care delivery. The management team had the skills and knowledge to improve the care being provided for people at the service. They used an action plan to monitor progress of the actions being set which was reviewed with the staff team aiming to achieve the best outcomes possible. The registered manager understood the needs of people living at the home, including their individual circumstances and factors that motivated them. The registered manager told us, “We want staff to be sensitive towards people's individualities and receptive towards their communication, not pushing or rushing it.”

Service improvement plans were in place and through these and the strengthened governance programme, improvements had been made at the service. There was a strong focus on reflection and learning, in order to improve practice.