Mandeville Grange Nursing Home

Updated 7 January 2025

Date of inspection 20 January 2025 to 5 February 2025. The service is a nursing home providing care and support to older people, including people with dementia. At the time of this inspection 17 people were living at the service. The inspection was conducted in response to concerns identified by a coroner following an inquest. We found 6 breaches of regulations relating to safe care and treatment, staffing, safeguarding, consent, governance and notifications the provider is required to make to CQC.

Governance systems were ineffective and failed to identify the significant concerns we found with the way the service was managed. People were not safeguarded and risks to them were not identified and mitigated, with systems not embedded in practice to promote learning to prevent reoccurrence of incidents. Safe medicine and infection control practices were not promoted. Staffing levels were not sufficient with staff not suitably trained or adequately supported in their roles. Records were contradictory, and the service failed to notify CQC of events which they are required too. This did not promote an open and transparent culture.

We have taken civil enforcement action against the provider and served warning notices for them to make the required improvements.

This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

Updated 7 January 2025

Some people and relatives were happy with the care provided. They told us they felt safe and gave examples why, such as access to equipment like call bells and walking aids. They confirmed they had access to the GP for their medical needs. Some people said that staffing levels varied and at times staff were rushed and did not have time to talk with them. While people expressed general satisfaction with their care, our inspection found elements of care did not meet the expected standards.

We carried out a short observational framework for inspection (SOFI). We observed most of the people who were sat in the lounge at lunchtime went to their bedrooms and bed early. A person told us, they get up late and go to bed early. They confirmed this was not their choice and their care plan did not outline the rationale behind that decision. Whilst the service had an activity staff member, some people told us activities were limited and not of interest to them. We noted the activity staff member was busy supporting people with their meals and providing supervision to people sat in the lounge, which reduced their ability to provide activities outside of the lounge area. We observed staff used terms of endearment such as ‘lovey’ and ‘darling’ when engaging with people. People’s care plans did not indicate people wished to be referred to in that way and this practice did not promote people’s dignity and respect.

Some relatives did not recall being asked their view on the service and whilst some people knew who the manager was, others did not. People told us if they had any concerns they would talk to one of the staff.