Date of Assessment: 9 September to 25 September 2025 Mayfair Homecare - Barnet is a domiciliary care agency that provides care and support to people living in their own homes. The service supported older people some of whom lived with dementia. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. At the time of our inspection 75 people were being supported with personal care. This inspection was to follow up on actions from the last inspection in July 2022. At that inspection. The provider was in breach of legal regulations in relation to safe care and treatment. Improvements were found at this inspection and the provider was no longer in breach of regulations. As part of our assessment methodology for services who may support people with a learning disability and autistic people, we assess if services are meeting the Right Support, Right Care, Right Culture (RSRCRC) statutory guidance. This includes: Right support: Model of care and setting maximises people's choice, control and independence. Right care: Care is person-centred and promotes people's dignity, privacy and human rights. Right culture: Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives. The service was not supporting anyone with a learning disability or an autistic person at the time of our inspection. Care plans included guidance for staff on maintaining people’s safety, and these procedures were followed. Risks to people were identified and addressed. The service maintained sufficient staffing levels to ensure both the safety and the fulfillment of people’s needs. People were empowered to make choices and participate actively in their care planning. Safeguarding measures were robust, and people received appropriate support with their medicines. Systems were in place to record and learn from accidents and incidents. The provider regularly assessed people’s capacity for decision-making and delivered personalised care. Service quality was monitored through established processes, driving ongoing improvement. Staff benefited from training and support, enabling their professional development. People were always treated with dignity, kindness, and respect. Their privacy was protected and their individual needs, including equality and diversity needs, were fully supported. The leadership team was knowledgeable, supportive, and fostered a positive, inclusive culture.
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First inspection of Mayfair Homecare - Barnet rated Requires Improvement overall, with a breach of Regulation 12 due to discrepancies in medicines administration records. Concerns also included late visits, ineffective audits and absence of a registered manager, although caring, effective and responsive domains were rated Good.
Concerns (9)
criticalMedication management: “We found discrepancies in several people's medicines administration records (MAR) which meant there was a risk people did not receive their medicines as prescribed.”
criticalMedication management: “staff signed the MAR for these medicines as 'NR' ('not required'), and did not provide any explanations why these medicines were not administered.”
criticalMedication management: “One person took a medicine once a week on a Monday as instructed on the MAR, but their MAR contained signatures on consecutive days which meant they had not received their medicine as prescribed.”
moderateMissed or late visits: “some people and their relatives told us staff were sometimes late when attending to their care visits or did not always stay for the whole duration of the visits.”
moderateCommunication with families: “Some people and their relatives also told us they were not always notified if their care staff were running late.”
moderateStaffing levels: “Several staff members felt they did not always have enough time to complete their tasks due to the complex needs some people had.”
moderateGovernance: “existing quality checks had not identified the issues we found at this inspection.”
moderateGovernance: “Medicines audits did not identify the discrepancies we found with people's medicines records.”
moderateLeadership: “At the time of our inspection there was not a registered manager in post.”
Strengths
· People were safeguarded from abuse and staff were fully aware of their duties to report concerns
· Comprehensive risk assessments with person-centred guidance for staff
· Safe recruitment processes including DBS checks and references
· Infection prevention and control measures including PPE access and training
· Thorough induction, mandatory training, refresher training, supervision and annual appraisals for staff
Quality-Statement breakdown (21)
safe: Using medicines safelyRequires improvement
safe: Staffing and recruitmentNot rated
safe: Systems and processes to safeguard people from the risk of abuseNot rated
safe: Assessing risk, safety monitoring and managementNot rated
safe: Preventing and controlling infectionNot rated
safe: Learning lessons when things go wrongNot rated
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawNot rated
effective: Staff support: induction, training, skills and experience
Not rated
effective: Supporting people to eat and drink enough to maintain a balanced dietNot rated
effective: Supporting people to live healthier lives, access healthcare services and supportNot rated
effective: Ensuring consent to care and treatment in line with law and guidanceNot rated
caring: Ensuring people are well treated and supported; respecting equality and diversityNot rated
caring: Supporting people to express their views and be involved in making decisions about their careNot rated
caring: Respecting and promoting people's privacy, dignity and independenceNot rated
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesNot rated
responsive: Meeting people's communication needsNot rated
responsive: Improving care quality in response to complaints or concernsNot rated
responsive: End of life care and supportNot rated
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements; Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringNot rated
well-led: Engaging and involving people, the public and staff; duty of candour; working in partnership with othersNot rated