CQC report explained · a nursing home
What the CQC found at Mandale Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2023
Mandale Care Home was rated Requires Improvement after inspectors found serious safeguarding and management weaknesses, although medicines and staffing were generally safe.
This was an unannounced focused inspection. Inspectors visited on 26 January 2023 and reviewed the Safe and Well-led areas. They spoke with people, relatives and staff, and checked care records, medicines records, recruitment files, audits and training records.
Inspectors found that people were not always protected from avoidable harm. Staff did not always report serious incidents, assess risks properly or take action to prevent incidents happening again. Some important incidents had not been reported to the local authority, police or CQC.
There were also weaknesses in management oversight and quality checks. The provider acted straight after the inspection by starting an investigation, making referrals and improving its systems. However, the service was still rated Requires Improvement overall, with Safe and Well-led both rated Requires Improvement.
The previous overall rating was Good, published in July 2019. The other three areas were not inspected during this visit, so their previous ratings were used when calculating the overall rating.
Medicines
Inspectors found that medicines were stored securely and generally given as prescribed and on time. There were some gaps in records for creams and lotions.
“Medicines were stored securely, and people received their medicines as prescribed and at the right time.” from the report
Staff recruitment
The home had enough staff to meet people's needs at the inspection, and recruitment checks were completed safely. There were vacancies and some people said staff could be rushed.
“Appropriate pre-employment checks were completed to ensure the workforce was suitable to work with vulnerable people.” from the report
Kind interactions
Inspectors saw kind interactions between staff and people. People also said they liked the staff.
“Kind and caring interactions between staff and people were observed.” from the report
Working with professionals
Staff made timely referrals and sought medical help when appropriate.
“Staff engaged well with other professionals. Medical attention was sought where appropriate.” from the report
Safeguarding failures
seriousStaff did not take appropriate action after repeated incidents involving risk of harm. Concerns were not properly escalated or referred to the local authority, police or CQC.
“Staff had not followed safeguarding procedures in respect of the incidents.” from the report
Incomplete risk plans
seriousSome care plans did not contain enough information to help staff manage risks safely. One person's oxygen therapy plan did not explain the risks or safe management clearly enough.
“People's care and support plans did not always contain complete information to help staff support them safely.” from the report
Weak management checks
seriousThe home's quality systems did not reliably identify missed actions, repeated incidents or failures to notify CQC. This was a breach of good governance requirements.
“The governance and quality monitoring of the service was not robust enough to ensure people were protected from the risk of harm.” from the report
Training gaps
needs fixingSome staff needed refresher training, including moving and handling. Training was also not always specific to people's needs, including mental health and oxygen therapy.
“Some staff required refresher training in mandatory areas such as moving and handling.” from the report
Recording gaps
minorCreams and lotions were reportedly applied appropriately, but the records did not always show this clearly.
“This was not always reflected in the records for creams and lotions which contained some gaps.” from the report
- 01What new system is now used to make sure every safeguarding incident is reported to the manager, the local authority, police and CQC when required?
- 02How are risks, including risks linked to oxygen therapy and repeated incidents, now assessed, recorded and reviewed?
- 03Which staff have completed refresher training in moving and handling, mental health and oxygen therapy, and how do you check that training is effective?
- 04How are managers checking that incidents are followed up and that actions to prevent them happening again are completed?
- 05How are gaps in records for creams and lotions being checked and corrected?
This was an unannounced focused inspection of Safe and Well-led only; the other three key question ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 25 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2021
Mandale Care Home was inspected but not rated; inspectors found good infection control during the COVID-19 outbreak.
This was an announced, targeted inspection on 13 January 2021. It looked at infection prevention and control because of coronavirus outbreaks in care homes.
Inspectors found the home was managing infection risks well. People were monitored for symptoms, testing was available, and isolation measures were in place. The home was clean and staff used protective equipment safely.
The home was closed to visitors under government guidance. People kept in touch with relatives by telephone, video calls and window visits. A visiting pod was ready for future use.
The service was inspected but not rated. This means the inspection did not give a usual overall quality rating or full ratings for all five areas.
Infection control policy
The home had a current infection control policy backed by coronavirus-specific procedures.
“There was an up to date infection, prevention and control policy in place supported by COVID-19 specific protocols.” from the report
Clean environment
The home was clean, with detailed cleaning records and regular cleaning of surfaces that people touched often.
“The care home was kept clean. Staff kept detailed records of their cleaning schedules” from the report
Safe protective equipment
There was enough protective equipment, staff used it correctly, and it was disposed of safely.
“Staff were using this correctly and in accordance with current guidance and disposal was safe.” from the report
Monitoring people's health
People were monitored for coronavirus symptoms, including through temperature and oxygen checks, so changing needs could be identified.
“Additional monitoring such as temperature checks and oxygen levels were carried out so that people's changing needs could be quickly identified and responded to.” from the report
Family contact
Although visitors could not enter during the outbreak, people stayed in contact with relatives through calls, video calls and window visits.
“People maintained contact with family through telephone calls or 'face time,' which had enabled people to speak to each other and window visits.” from the report
Inspectors raised no specific concerns in this report.
- 01What are the current visiting arrangements, and can relatives use the visiting pod?
- 02How are people and staff currently tested for infections?
- 03How often are high-touch surfaces cleaned, and can families see the cleaning records?
- 04How are new admissions isolated and monitored for symptoms?
- 05What were the most recent full ratings for Effective, Caring, Responsive and Well-led?
This was a targeted inspection of infection prevention and control under Safe only; the service was inspected but not rated and the other areas were not assessed. This explanation was written from the published report of 20 January 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Mandale Care Home
5 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- February 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2021Inspected but not ratedSafe: Inspected but not rated
- August 2020Inspected but not ratedSafe: Inspected but not rated
- July 2019Goodup from Requires improvementSafe: GoodWell-led: Good
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2017Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Good
- April 2015Requires improvementSafe: GoodEffective: InadequateCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 21 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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