CQC report explained · a nursing home
What the CQC found at Mandeville Grange Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, March 2021
Inspected but not rated; inspectors found good infection prevention and control measures during the COVID-19 pandemic.
Inspectors visited the home on 11 March 2021. This was an announced, targeted inspection focused on infection prevention and control during the COVID-19 pandemic.
They found good practice in how people kept in touch with families, including individual visiting plans and a booking system. Visitors were tested, screened and given clear information and protective equipment.
Inspectors were assured about the home's use of protective equipment, testing, hygiene, social distancing, safe admissions and its plans for preventing or managing outbreaks. The service was inspected but not rated.
Family contact
The home used individual visiting plans and a booking system to help people keep in touch with their families while limiting visitor numbers.
“People were supported to keep in touch with their families throughout the COVID-19 pandemic.” from the report
Visitor safety
Visitors were received in a separate area, given guidance and protective equipment, and had health screening and temperature checks.
“Visitors entered via a buzzer system, were received into a separate area on arrival where they were provided with guidance, personal protective equipment (PPE) and health screening was completed.” from the report
Protective equipment
Inspectors found enough masks, gloves, aprons and hand sanitiser. Staff had training in infection prevention, protective equipment and hand hygiene.
“There were sufficient supplies of PPE including masks, gloves, aprons and hand sanitiser.” from the report
COVID-19 testing
Regular COVID-19 testing was in place for staff and people living at the home, allowing action to be taken quickly after positive results.
“A regular programme of testing for COVID-19 was in place for staff and people who lived in the service.” from the report
Inspectors raised no specific concerns in this report.
- 01How have your infection prevention and control arrangements changed since the inspection on 11 March 2021?
- 02What are your current arrangements for family visits and visitor testing or screening?
- 03How do you make sure there is enough protective equipment and that staff use it safely?
- 04How often are staff and residents currently tested for infections?
- 05What were the ratings and findings for areas of care that this targeted inspection did not cover?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it was inspected but not rated and did not assess all areas of care. This explanation was written from the published report of 24 March 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.
What inspectors found, August 2018
Mandeville Grange Nursing Home was rated Good; inspectors found kind, safe care and significant improvement since the previous inspection, with some staffing and record-keeping issues.
This was an unannounced inspection on 3 and 7 August 2018. The inspector reviewed care plans, medicines, recruitment and training records, maintenance records and safety certificates. They spoke with people living at the home, relatives, staff, managers and outside health and social care professionals.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were protected from abuse, medicines were managed safely, care was personalised, and staff were kind and respectful. People had access to activities, healthcare and family visits.
There were some issues to monitor. Staff said they felt stretched in the mornings. Water temperatures had been recorded too low on three occasions, and the system for recording certain legal applications could be better managed. The manager said action had been taken or would be made in these areas.
Safe medicines
Inspectors found medicines records were completed properly. Staff understood people's medicines, including medicines prescribed for occasional use.
“We found MARs to be completed appropriately. People told us they were supported with their medicine in a safe manner.” from the report
Kind and respectful staff
Staff knew people well and showed compassion. People said they were listened to, acknowledged and treated with dignity.
“We observed staff were kind and caring in their approach to working with people.” from the report
Personalised activities
People could take part in group or individual activities, including activities outside the home. The programme could be changed to suit individual wishes.
“Group and individual activities took place. Where people chose to stay in their room, the activities co-ordinator visited people in their room.” from the report
Approachable management
People, relatives and staff spoke positively about the way the home was managed. The manager was available and acted on feedback.
“The registered manager operated a 'open door' policy.” from the report
Improvement since the last inspection
The previous focused inspection found a breach involving pre-employment checks. At this inspection, the required checks were in place and the report recorded significant improvement.
“At this inspection we found significant improvements had been made.” from the report
Morning staffing pressure
needs fixingStaff said they felt stretched and wanted more help, especially in the morning. The manager said staff deployment was being reviewed, although inspectors saw call bells answered quickly and people's needs attended to in good time.
“However, when we spoke with staff they told us they were stretched and they could do with more help, especially in the morning.” from the report
Water temperature records
needs fixingWater temperatures had been recorded too low on three occasions, and the manager was initially unaware. The manager confirmed that action had been taken before inspectors left.
“We found the water temperature had been recorded too low on three separate occasions.” from the report
Recording legal applications
minorRecords of applications and decisions relating to restrictions on people's liberty were kept in the main diary. Inspectors asked for this recording to be managed better, and the manager agreed to make changes.
“We spoke with the registered manager about how the recording of application and decision could be better managed.” from the report
Limited questionnaire feedback
minorThe home sought feedback through questionnaires, but only two replies had been received from the latest questionnaires sent out. This may limit how much feedback the home receives through that method.
“However, the service only received two replies from the last questionnaires sent out.” from the report
- 01How many staff are planned for mornings, and what changes were made after staff said they felt stretched?
- 02What checks are now in place to make sure water temperatures stay safe and any low readings are acted on promptly?
- 03How are applications and decisions relating to restrictions on people's liberty recorded and followed up now?
- 04How will you gather enough feedback from people and relatives when questionnaire responses are low?
- 05What quality audits are currently being carried out, and how are actions checked until they are complete?
This was an unannounced inspection covering all five areas of quality, including care, medicines, staffing, records, the environment and how the home was managed. This explanation was written from the published report of 31 August 2018 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 Mandeville Grange Nursing Home
3 rated inspections over 2 years: the service has held its Good rating throughout.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Mandeville Grange Nursing Home →
- August 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Mandeville Grange Nursing Home →
- April 2017Goodstayed GoodSafe: Requires improvement
- April 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- August 2011
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 12 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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