Mandeville Grange Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continuallyidentifyand embed good practice.

The service had a strong, embedded learning culture, with all incidents, accidents, concerns and feedback systematically reviewed. The registered manager used these as opportunities to identify lessons learned, refine practice and communicate improvements to staff. Staff spoken with were clear of the process for reporting incidents and told us they felt confident raising concerns, which were responded to promptly.

Regular meetings were held, including daily, weekly and monthly meetings, as well as quarterly health and safety and ambassador forum meetings (staff with lead roles in areas such as dementia, well-being and safeguarding). These enabled shared learning and kept staff fully informed of service developments to support safe care with minutes of the meetings provided to staff unable to attend a meeting. Records demonstrated staff had read and understood meeting outcomes, supporting a culture of continuous learning, honesty, transparency, confidence and accountability. Lessons learned shaped practice and informed decision-making ensuring people received person centred care with staff consistently equipped with the skills and knowledge needed to deliver care safely, effectively and in line with people’s individual needs.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service maintained safe and well monitored systems to ensure care was coordinated and responsive to people’s needs. Staff worked collaboratively with people, families and healthcare professionals such as dieticians, tissue viability nurses, speech and language therapists (SALT) and specialist teams such as mental health teams.

The service had systems in place to promote safe transitions to and from the service. For emergency admissions to Hospital, an up-to-date hospital passport was printed off from the electronic care plan system and sent to hospital with the person with medicine and medicine records. The registered manager told us for a recent admission to hospital staff accompanied the person as the relatives were not available and the person needed that level of support. Scheduled moves of any individual out of the service are planned with written and verbal handovers provided which promotes a safe transition.

A professional involved with the service told us, “I have found communication with the team to be timely and effective. The service responds promptly to residents’ health needs and arranges appointments or follow-up actions without unnecessary delay, supporting continuity of care.” They told us from their observations, staff provided person-centred care and showed a good understanding of residents’ individual needs. They commented, “Residents appear comfortable and well supported, and staff interactions are respectful and caring.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The service had policies and procedures in place to safeguard people from abuse. Staff were trained in safeguarding with posters displayed to remind them of the process for reporting. Incidents of potential abuse were reported to the relevant agencies in line with safeguarding procedures. The provider always shared concerns quickly and appropriately.

Staff demonstrated strong knowledge and confidence regarding safeguarding procedures. They provided clear, concise accounts of their individual and collective roles in protecting vulnerable people from harm and effectively outlined the internal reporting processes. Staff commented, “I have received safeguarding training, and I have learned how to recognise signs of abuse, how to protect vulnerable people and the correct procedure for reporting any concerns immediately, internally to my line manager and externally to the local Safeguarding team and a CQC notification.” and “I would report any and all abuse whether it be physical, financial, emotional or neglect. My role is good because I have got to know the residents and I would see if they were withdrawn or not acting like their usual self. If I saw abuse, I would report it to the lead nurse, if I was not helped, I would follow the escalation policy. I also know I could seek help for the person from outside of the home from the local authority, CQC and Police.”

People told us they felt safe and relative felt confident their family members were safe and safeguarded.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service maintained a risk register which provided an overview of identified risks to people. This enabled them to have oversight of risks to ensure risks were identified, mitigated and reviewed. It was also used to inform people’s dependency needs, helping to determine appropriate staffing levels.

There were risk assessments to guide care staff which were clear, concise but also very detailed without overloading the reader with irrelevant information. Risk assessments had been completed to be user friendly and were written in a person-centred and compassionate way. We saw how the managers responded to recent incidents. They checked the immediate risks were addressed promptly without delay.

Staff had a good understanding of people’s needs and risks. A staff member commented, “I closely monitor people, follow their care plans and ensure appropriate risk assessments are in place. I ensure we have the appropriate staff ratio for supervision and support and assistance as required. The registered manager and clinical lead complete a risk register which is updated minimum monthly and it is discussed with us to know areas of risk and support needed.”

Relatives reported that they felt risks to people’s safety were managed effectively. They gave examples, including the use of puree foods for those at risk of choking, hoists assisting people to move positions, and sensor mats and/or bed rails for people at risk of falls. Relatives expressed confidence in staff’s capability and experience to manage risks appropriately.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was undergoing a programme of renovation and improvement works, including upgrades to the kitchen, bedrooms, installation of en-suites facilities as well as the replacement of windows and the heating system. Further works were planned to continue the refurbishment.

The provider had Personal Emergency Evacuation Plans (PEEP) for people, these were done to an exceptional standard, they detailed and addressed specific mobility, sensory, and cognitive impairments, ensuring a swift, and safe exit, featuring specialised equipment required. We also saw each plan was person centred, documenting comprehensive, specific personal details about people which was easy to read.

The provider held up‑to‑date certificates for key safety systems, including gas safety, fixed electrical wiring, fire safety systems such as emergency lighting, alarms and extinguisher servicing, portable appliance testing (PAT), legionella testing and Lifting Operations and Lifting Equipment Regulations (LOLER) inspections for hoists and beds.

Regular fire checks were carried out, including checks of emergency lighting, fire doors and fire detection systems. An up-to-date fire risk assessment was in place. Fire drills were conducted during day and night shifts, including simulated scenarios to support staff to practice their response in the event of a fire. This enabled staff to practise and develop the confidence and skills needed to respond effectively in the event of a fire.

The registered manager was responsible for completing regular audits of the service which included health and safety audits and audits of the environment. They enrolled and implemented staff members to take on extra responsibilities and training to enable them to carry out daily ‘health and safety walk abouts’ to ensure people’s safety, compliance and to proactively prevent accidents and incidents from occurring. This fostered a safety-first culture, boosting staff confidence and morale, reducing operational risks, and improving the overall quality of life for people using the service.

At the inspection we spoke with the maintenance team and health and safety lead who were able to provide knowledge, understanding and commitment to a shared responsibility approach to health and safety, proactive, no-blame culture that was driven by strong leadership from the registered manager.

The provider made sure there were always enough qualified, skilled and experienced staff, who received thorough support, supervision and strong development opportunities They worked well together to provide safe care that met people’s individual needs.

Staffing arrangements were well managed and consistently maintained to meet people’s needs safely. The provider used a dependency tool to determine staffing requirements, and rotas reflected these levels were consistently maintained, enabling flexible, responsive care. Volunteers supported non care activities, allowing care staff to focus on people’s needs.

Staff told us the staffing levels were sufficient and adapted to changing dependencies. A staff member commented, “Staffing levels are organised to meet people’s needs effectively. During busy times, nights or weekends, we work together as a team to ensure people receive safe care. Some people do require support from 2 staff members, and this is always planned for to maintain safety and wellbeing,” and “I feel staffing levels are generally planned to meet people’s needs safely, based on their care plans and risk assessments.”

Relatives reported the staffing levels seemed sufficient, especially with the current number of people in the service. A relative commented, "It seems there are a lot of staff around, who are accessible and very approachable. Staff are really friendly and helpful. I am very comfortable with the staffing levels. [Family member] is happy with them and says staff are very nice and caring. I have nothing but good experiences with the staffing levels, their friendliness and professionalism.”

All staff received induction, supervision and on-going training, including mandatory training as required for the service and specialist training to support them in meeting people’s needs. Training records showed the training was up to date with prompts in place to ensure updates were completed on time. The registered manager ensured staff received person specific training prior to people being admitted, for example in Percutaneous Endoscopic Gastrostomy (PEG) care so they had assured themselves staff were competent and confident to provide safe care. In addition, staff were coached and supported to develop their skills before additional responsibilities were delegated.

The registered manager had recently introduced a competency framework for care staff, observing and assessing their practice across all aspects of their role, such as care delivery and other general working practices such as fire. The framework enabled the registered manager to satisfy themself staff were suitably skilled for their roles and to identify any gaps, providing additional training where required. In addition to formal training the registered manager regularly used practical exercises and scenario-based training to assess whether training had been embedded in practice. This included unplanned Cardiopulmonary Resuscitation (CPR) drills, discussions prompting staff to explain how they would respond in the event of a choking incident and walkthrough of fire drill procedures and discussions. This enabled the registered manager to validate staff competencies, address any gaps, and ensure training was effectively applied to deliver person centred care. Staff were supported and supervised through regular one to one meetings.

In addition, the registered manager held monthly team meetings and facilitated discussions reflecting on lessons learned from incidents, feedback or concerns. Positive feedback was also shared with staff to recognise good practice and motivate them. This approach ensured learning was fully embedded in practice, to enhance safety, quality and person-centred care. The registered manager operated an open-door policy, which allowed staff to access support and seek guidance whenever needed.

Recruitment processes were thorough ensuring staff suitability for their roles. Files contained all required checks, such as a check for criminal convictions and uptake of references. Each qualified nurse was currently registered with the Nursing and Midwifery Council (NMC). Registration numbers and renewal dates were verified using the NMC online register.

Together, these systems ensured staffing was well managed, staff were competent and confident, and able to deliver care that was safe, personalised and delivered in line with recognised evidence-based practice.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was clean, hygienic with systems in place to maintain a high standard of cleaning, including cleaning of equipment such as wheelchairs and hoists. Cleaning schedules were in place which were signed off when completed.

Staff were trained in infection control, and policies were in place to guide their practices. Infection control procedures were regularly audited to ensure compliance. The service had a named staff member as an infection control ambassador who had responsibility for the oversight of infection control. Personal protective equipment (PPE) stations were located throughout the service and accessible to staff.

At the time of the inspection there were no infections likely to cause cross infection. The service had systems in place to monitor and manage infections, such as Methicillin- Resistant Staphylococcus Aureus (MRSA) to mitigate the risk of transmission.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored securely and keys to the medicines room were restricted to authorised staff only. Staff carried out daily stock checks. We completed a random check of medicines and no discrepancies were found. Room and fridge temperature monitoring was taking place daily. Medical equipment was periodically calibrated and tested.

People received medicines safely and as intended by the prescriber. Electronic medicine administration records (MARs) were in place which provided staff with accurate information about the medicines. Each MAR profile included a personalised landing page which explained how the person preferred to take their medicines, enabling staff to provide person-centred care. Medicines were administered in a timely manner and recorded on the electronic medicines administration record. People receiving insulin had appropriate blood glucose monitoring and staff used insulin charts to indicate the site of injection and ensure site rotation. Application of topical products (creams) was indicated on a topical MAR. There was no evidence found of inappropriate use of medicines to control behaviour.

People’s care plans had the necessary information to support them with their health needs and prescribed medicines. The service identified medicines with additional risks which should be managed and monitored as well as appropriate management plans for people with diabetes.

The service had a robust auditing system which provided assurances medicines were being given safely and as prescribed. Audits successfully picked up on issues which were actioned and learning was disseminated. The service kept a log of patient safety alerts with evidence of action taken where appropriate.

Staff received training in the medicines management annually which includes competency assessments.