Mandeville Grange Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

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

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 79 (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 very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The registered manager had a clear vision and set of values for the service, centred on openness, strong leadership and inclusivity. They ensured staff felt valued, supported and actively involved in the service’s progress. They fostered a sense of community, promoting belonging and effective teamwork where staff were encouraged to share ideas and strategies to improve the service and deliver high quality care. They were committed to continuous improvement and proactive culture which empowered staff to reduce risks, and where challenges were viewed as opportunities to learn and improve outcomes for people.

The registered manager led by example, working alongside staff and providing clear guidance, training and oversight while maintaining accountability for delegated responsibilities. They also undertook 360 – degree supervision, enabling staff to provide feedback on both their own practice and the registered manager’s leadership. This approach promoted openness, honesty, transparency, strengthened relationships and supported a culture of continuous learning and improvement.

Staff spoke positively about the registered manager, describing them as genuinely caring and valuing the team which helped ensure the delivery of high-quality care to people. They told us morale was high because of the support they received from the management team. Staff commented, “Staff morale is positive. Everyone works well together, supports each other, and there’s a strong team spirit, which helps us provide the best care for residents,” and “Everything has changed here for the better, with issues dealt with in a non-confrontational positive way. “

Relatives told us they felt the service provided a more supportive environment and that care was more inclusive. They also noted that more activities were taking place, contributing to a positive and engaging atmosphere and reinforcing a culture that promoted people’s well-being.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager demonstrated a clear understanding of their role and responsibilities which was reflected in the consistent oversight and effective running of the service. Improvements made within the service demonstrated their knowledge, skill and competence in leading and managing the service and their ability to drive and sustain positive change.

Staff, people and their relatives spoke positively about the registered manager describing them as ‘approachable, supportive, responsive.’

Relatives told us they were happy with how the service was managed and valued the improvements the new registered manager had implemented. They described the management as excellent and said they listen and respond in a way that meets their expectations. Overall, relatives felt communication was good and they were kept updated on their family member’s care

Staff spoke positively about the registered manager’s leadership. A staff member described them as “a strong, team - orientated leader” who was inclusive and respectful. They said the registered manager held regular meetings, shared knowledge and supported staff to develop and succeed. Another staff member told us, “I feel well supported in my role. The manager and senior staff provide guidance, regular feedback, and opportunities for training, and colleagues work together to offer help whenever needed.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Systems were in place to promote people and staff to speak up. People had the opportunity to express their views through resident meetings and the appointed resident ambassador.

The service had implemented a “You Said, We Did” display board, which encouraged people and their families to share their feedback and suggestions. The registered manager told us, “This initiative demonstrates that we actively listen and respond to the views of those in our care, promoting transparency and trust. It also helps to show how feedback leads to meaningful improvements within the home, reinforcing a culture where everyone feels heard and valued.”

People and relatives told us they know how to raise concerns, and they felt confident issues raised would be addressed. Relative meetings were facilitated providing further opportunities for speaking up.

The service had a whistleblowing policy in place with frequent opportunities provided for staff to raise concerns. Alongside this staff had access to one-to-one supervisions and the registered manager operated an open-door policy which helped ensure concerns could be raised safely and addressed promptly.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Systems were in place to support staff with their religious, cultural and individual needs. Staff had access to equality, diversity and inclusion training with guidance provided through the provider’s policies, which supported and inclusive and respectful workplace culture.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The service was well governed and effectively managed. A structured programme of audits was in place, with a schedule outlining the frequency of checks, including monthly and quarterly audits. The registered manager maintained oversight by reviewing audits completed by staff and produced a monthly report to monitor themes, identify any gaps and drive improvements. Audits were used to develop action plans to address any shortfalls and plan improvements to the service. In addition, the provider carried out regular monthly visits to the service to provide further oversight and assurance. These systems supported ongoing monitoring and continuous improvement. Further improvements were planned to the auditing systems with a dedicated compliance and governance platform. The platform will support the quality assurance framework by enabling audit management, mock inspections and real time compliance monitoring.

Records were generally well organised, accessible, up to date and relevant. In care plans we reviewed we found contradictions and inconsistencies in one person’s International Dysphagia Diet Standardisation Initiative (IDDSI) food level and for another person, in the use of moving and handling equipment. This was fed back to the registered manager, who took immediate action to address the issue and implemented measures to prevent a reoccurrence. This demonstrated the service’s approach to maintaining accurate records to ensure continuous improvement and mitigate risks.

The provider had a range of relevant policies and procedures in place to support the safe and effective running of the service. These were regularly reviewed and updated to reflect current guidance and practice. Policies were discussed with staff in team meetings to ensure understanding and staff were required to sign to confirm they had read and understood them. This supported staff to work consistently in line with the provider’s expectations and best practice.

The registered manager demonstrated a good understanding of their regulatory responsibilities including the requirement to notify the Commission of relevant events. They were open, honest and transparent in their approach to managing the service promoting a culture of continuous improvement.

The service produced a monthly newsletter for people, families and staff, providing updates on events, activities, service improvements, staff changes and a message from the registered manager. This promoted transparency and kept people, their relatives and staff informed and engaged about life at the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Professionals told us, “The manager is proactive with us and local health teams. The manager is very experienced and leads the team with kindness and compassion.” and “I have found communication with the team to be timely and effective. The service responds promptly to people’s needs”.

The service had recently engaged with Duke of Edinburgh Award volunteers, providing opportunities for young people to gain valuable experience while contributing to the day-to-day life of the home.

The registered manager was also working in partnership with NHS England’s Choices College to support students through work experience and internships. These partnerships strengthened links with the local community, promoted learning and supported the services wider community engagement.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The service had a range of learning systems in place to support continuous improvement. These included their “Lessons Learnt” process, which helped them to reflect on and learn from any mistakes or events. These were shared and discussed during all staff meetings when new lessons had been identified. These enabled open conversations and ensured key learning was communicated effectively across the team.

The registered manager had developed a care ambassadors’ system, with staff expressing an interest in further developing their knowledge and skills across a range of key areas. These included end of life care, dementia, health and safety, nutrition and wellbeing, safeguarding, dignity, and freedom to speak up.

Relatives were encouraged to provide feedback via the carehome.co.uk website. Feedback from external professionals was requested with all feedback reviewed to help the service continue to develop, learn and improve care.

Since the previous inspection, the service had taken proactive steps to address the areas of concern and improve the quality of care. The registered manager played a key role in implementing robust systems and practices to address previous breaches of regulations. As a result, the service was no longer in breach of regulations. These improvements demonstrated a commitment to continuous learning and improvement promoting safe person-centred care.