Updated 29 April 2025
Mandale Care Home is a care home providing accommodation and personal care for older adults, younger adults, people living with dementia and people with a learning disability. Staff were not supporting anyone whose primary need was associated with a learning disability or autism. Mandale Care Home is registered to accommodate up to 57 people. At the time of the assessment, there were 42 people using the service. Dates of assessment 1 May 2025 to 16 May 2025. At the last inspection in December 2024, we rated this service overall good.
The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of falls from height. This inspection examined those risks.
At this assessment we found the service was not always identifying risk and taking appropriate action. There was a lack of robust record keeping and effective oversight from the management and provider and a breach of regulation 17 was found.
The service has been rated requires improvement in safe and well-led. Improvements were needed to provider oversight and quality monitoring systems. Safe recruitment practices were followed and there were enough staff to meet people’s needs. Staff were knowledgeable of safeguarding procedures and how to keep people safe from harm and abuse. There was a registered manager in post who was supported by a regional manager and the provider.
Governance systems were in place; however, audits were not always effective in identifying shortfalls. For example, in relation to effective record keeping to identify risk. The leadership team were responsive to feedback and made some immediate improvements. They also offered assurances on the action they would take to embed and sustain improvements.