Mandale Care Home

Updated 25 February 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

2 inspectors and an Expert by Experience carried out the inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Mandale Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Mandale Care Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post. The registered manager was due to leave shortly, and a new manager had been recruited.

Notice of inspection

This inspection was unannounced.

Inspection activity started on 26 January 2023 and ended on 7 February 2023. We visited the service on 26 January 2023.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used all this information to plan our inspection. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection

We spoke with 4 people who used the service and 10 relatives about their experience of the care provided. We spoke with and received feedback from 12 members of staff including the registered manager, the regional manager, the operations director, the quality manager, 2 senior care workers and 4 assistant care workers, 1 administrator and 1 domestic assistant.

We reviewed a range of records. This included 5 people’s care records, 3 staff recruitment files and multiple medication records. A variety of documents relating to the management of the service, including policies, audits and training records, were reviewed.

Updated 25 February 2023

About the service

Mandale Care Home is a residential care home providing personal care to up to 57 people. The service provides support to older people and people living with dementia. At the time of our inspection there were 38 people using the service. People were supported in an adapted building across 2 floors.

People’s experience of using this service and what we found

People were not always safe and protected from the risk of avoidable harm and abuse. Staff had failed to take appropriate action following a number of safeguarding incidents. The provider commenced an investigation and put systems in place immediately following our feedback, to minimise the chance of reoccurrence. Risks to people were not always robustly assessed, monitored or managed. The provider addressed this following our feedback.

Staff had not escalated safeguarding concerns to the registered manager, and the registered manager did not have oversight of all serious incidents which occurred within the home. Not all appropriate actions had been taken when things went wrong. Not all important incidents had been reported to CQC.

Some staff required refresher training in some areas. The provider had identified this and put a training schedule in place. We have made a recommendation about training.

Health and safety checks were in place and up to date. There were enough staff to support people and recruitment was ongoing. Safe recruitment procedures were in place. Medicines were managed safely. Suitable infection control procedures were in place.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff engaged well with other professionals and made timely referrals. The provider gathered feedback from people, relatives and staff. The registered manager was approachable and operated an open-door policy. Relatives spoke positively about the home and said they would recommend it to others.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 19 July 2019).

Why we inspected

We received concerns in relation to the environment, staffing, record keeping and the quality of care people received. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Following the inspection, the provider took action to mitigate the risks and issues identified.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mandale Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safeguarding and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

We have made a recommendation in relation to staff training.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.