Mandale Care 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

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 requires improvement. At this assessment the rating has remained requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance and oversight at the service.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider and registered manager had an action plan in place that identified improvements needed for the service and staff were involved in the process.

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.

Staff told us, “The manager is very approachable, kind and listens to staff I have no issues with management” and “We have a new resident who prefers females to support her and the manager makes sure it happens, it can be difficult but always ensures there is one female staff member.”

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

People, their relatives and staff were given opportunities to share their views with the management team. We received positive feedback regarding the registered manager from relatives and staff. One staff member told us, “We've had many managers, and it has an impact on staff. The manager involves all staff now, we are proud to be part of the service, and we can see how they want to get the home to be a good place.”

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.

Staff received equality and diversity training, and the staff team was made up of people of many different backgrounds and cultures. Staff had regular team meetings and one to ones that were meaningful and told us they were valued and felt supported in their work.

The provider did not have clear systems of accountability for oversight and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The registered manager and providers oversight and auditing processes were not effective. They failed to identify the issues found at this assessment regarding gaps in records and shortfalls which placed people at risk of harm.. This meant they were unable to ensure effective governance of 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.

Staff worked collaboratively and were confident to share any concerns or issues, for example safeguarding concerns. People were supported by a range of healthcare professionals, and this was reflected in people’s care plans. Collaboration with everyone involved when planning peoples care with them was evidenced.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider’s and registered manager audits and oversight didn’t identify the issues found at this assessment regarding gaps in records and potential risks at the service. We identified Infection, prevention concerns at our last assessment and there were new concerns relating to IPC at this assessment. This meant they were unable to learn and make improvements.