CQC report explained · a residential care home
What the CQC found at Mansfield
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe and there were enough staff to meet their needs. Inspectors found some weaknesses in recording injury monitoring and in the clarity of behaviour guidance.
- Effective?
- Good
- People's needs and health were assessed and monitored. Staff received induction, training and support, although records did not always show who had been involved in some best-interest decisions.
- Caring?
- Good
- Staff knew people well, treated them with dignity and supported their choices and independence. People and relatives were positive about the care.
- Responsive?
- Good
- Support reflected people's individual needs, communication styles, interests and goals. People were supported with community activities, holidays, relationships and end-of-life wishes.
- Well-led?
- Requires improvement
- The home had audits and staff felt supported, but leaders did not review incidents and low-level behaviours in enough detail to understand themes, patterns and lessons.
What inspectors found, February 2019
Rated Good overall; inspectors found safe, kind and personalised care, but the home was Requires Improvement for leadership and learning from incidents.
This was an unannounced, comprehensive inspection on 16 January 2019. Inspectors spoke with people living in the home, relatives and staff. They reviewed care records, medicines, training, recruitment, complaints and quality checks.
The home was rated Good for Safe, Effective, Caring and Responsive. People said they felt safe. Inspectors found enough staff, suitable medicines systems, clean surroundings, personalised support and good links with health professionals.
The Well-led rating was Requires Improvement. The home recorded incidents, but did not analyse low-level anxiety and behaviour in enough detail to identify patterns and prevent problems. Records about monitoring injuries and some mental capacity decisions were also not always complete.
The overall Good rating means inspectors found the care to be good across most areas, but the management concerns needed attention. The home had also been rated Good at the previous inspection in 2016.
People felt safe
People and relatives said staff helped people remain safe. Staff had safeguarding training and used procedures to respond to concerns.
“People were safe and protected from avoidable harm. Legal requirements were met.” from the report
Medicines were managed well
Inspectors found medicines were ordered, stored, given, recorded and disposed of correctly. Staff training and competency checks were in place.
“Medicines were correctly ordered, stored, administered, recorded and disposed of in line with national best practice.” from the report
Kind and respectful staff
Staff knew people well and supported them calmly, respectfully and with dignity. People were encouraged to be independent.
“People received care and support from a staff team that knew them well and had developed positive relationships with them.” from the report
Personalised activities and support
People were supported with their preferences, community activities, holidays, goals and communication needs.
“People received care and support that reflected their individual needs and preferences.” from the report
Incident reviews were not detailed enough
needs fixingThe home recorded incidents, but did not analyse low-level anxiety and behaviour for themes or patterns. Inspectors said this was a missed opportunity to understand why incidents happened and prevent them.
“The registered manager confirmed these were not reviewed to monitor behaviour to try and understand why incidents had occurred.” from the report
Injury monitoring was not recorded clearly
needs fixingBody maps recorded injuries, but daily records, handover information and health records did not show whether or how injuries were monitored. The manager said monitoring had taken place but had not been documented.
“However, people's daily records, staff hand over information and health records, did not show how and if, staff monitored these injuries.” from the report
Some care guidance and decision records needed improvement
minorBehaviour guidance was repetitive and difficult to follow. Records did not always show who had been involved in some mental capacity discussions and decisions.
“However, guidance to support staff of how to meet people's behavioural needs was repetitive and not easy for staff to follow.” from the report
- 01How do you now analyse incidents and low-level anxiety or behaviour to identify patterns and prevent them happening again?
- 02How do you record and review injuries after an accident or incident?
- 03How have you improved the clarity of guidance for staff supporting people's behaviour?
- 04How do you record who was involved in mental capacity assessments and best-interest decisions?
- 05What checks are now in place to make sure the improvements identified by the inspection have been completed?
This was an unannounced comprehensive inspection covering all five CQC questions, the care provided and the premises. This explanation was written from the published report of 9 February 2019 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 Mansfield
2 rated inspections over 3 years: the service has held its Good rating throughout.
- February 2019Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- November 2012
Registered with the Care Quality Commission on 30 November 2012.
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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