Mandale Care 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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service was in breach of legal regulation in relation to governance and effective record keeping of several different areas including care, cleaning, maintenance, kitchen and safety checks.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People and their relatives told us they felt safe living at Mandale Care home. However, we found learning issues and sustaining improvements since our last assessment.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

We found issues with infection prevention and control at the last assessment. Some areas had improved, however we found new cleanliness issues at this inspection.

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.

People received safe care and treatment and shared positive feedback with us regarding their care and support. Staff shared positive examples of how they ensure people are safe. One staff member told us, “Staff are the eyes and ears for people. The staff team raise concerns about service users i.e. not weight bearing, so other healthcare professionals can be involved, organised and care plans adjusted.”

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.

Staff were trained in safeguarding awareness and were able to share examples with us and understood how to keep people safe and how to spot and raise any concerns. One staff member told us, “I would look out for anyone being mistreated. I would raise with the manager, watch out for signs such as if resident appears fearful.”

The provider did not always work well with people to understand and manage risks. Risks were not always identified at the service due to gaps in record keeping.

Staff did not always provide care to meet people’s needs. We found gaps in record keeping in relation to repositioning changes to support people with their skin integrity. A ‘resident of the day’ programme was in place to support individuals in a more person centred way, identify any risks in their care or changes in their needs. We found this was not always carried out effectively by the staff team or registered manager.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There was not always robust record keeping in place to provide assurances that all health and safety checks were being carried out effectively or regularly. We found gaps in several areas including environment safety, required maintenance checks, domestic and kitchen cleaning, checks of peoples mobility equipment and care records.

The service lacked an accessible outside area for people to use safely. We received feedback from relatives regarding this and we also raised this with the registered manager who assured us there were plans to update the outside environment.

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

Staff recruitment was carried out safely and robust checks on new staff were in place. We observed adequate numbers of staff available to support people and meet their needs effectively.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Communal areas and bathroom cleaning had improved since our last assessment however, there were gaps in cleaning records and the cleaning schedules were not sufficiently detailed to maintain standards. Cleaning records for the kitchen had gaps and the fridges were not cleaned to an acceptable standard. Food was being served to people in their bedrooms without meal covers. The registered manager assured us that covers had been ordered.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.