Mandeville Grange Nursing Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment, and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last inspection we rated this key question good. At this inspection, the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support, and outcomes.

The service was in breach of legal regulation in relation to the assessment of people and consent.

This service scored 38 (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 did not make sure people’s care and treatment was effective by assessing and reviewing people’s health, care, wellbeing and communication needs with them.

Assessments of people moving into the service were not carried out in line with the provider’s policy. For the newest admission to the service their assessment was carried out remotely and the document was incomplete with sections of the assessment such as hearing, oral health, history of falls, pain, infection risk and dressing left blank. It was not established prior to moving if any specialist equipment was required. On admission to the service only a moving and handling assessment was completed. Care plans and risk assessments were not put in place until 2 and 6 days after admission. This placed the person at risk of unsafe care being provided.

Staff told us, communication was very poor, and they were not told enough about people moving into the service. They commented, “We do not have access to a person’s care plan until they are in the home, and this is on the system. By then you do not have time to read or digest any information about them but rather rely on colleagues or the individual themselves to find out more about them.” Kitchen staff commented, “I do not feel we got a lot of information about [person’s name}. We were informed on the day of admission that there would need to be another place for lunch.” The provider confirmed kitchen staff have full access via a PCS handset to all information relating to people’s nutrition and hydration needs, including new admissions. They confirmed it was the kitchen staff’s responsibility to check the device for that information.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

Staff did not follow safeguarding legislation or the Mental Capacity Act 2005 to safeguard people. They did not work to best practice guidance in relation to medicine management, assessments, care planning and risk management specifically relating to positive behaviour planning. Whilst staff told us they referred to the National Institute for Health and Care Excellence (NICE) guidance this was not evident in records viewed or staff practice.

There was no system in place for registered nurses’ professional development to promote evidence-based practice and no clinical meetings took place to discuss people’s clinical needs and improve the quality of care. Whilst some people and relatives told us they had seen their care plans, care plans did not evidence people and their relatives were involved in their development and reviews to promote their care and treatment.

The provider did not always work across teams and services to support people. They did not always share their assessment of people’s needs when people moved into the service.The service worked closely with other health professionals such as the GP and Mental Health Team. However, the communication systems within the service were poor. Information was not routinely shared in an effective way about new admissions and updates to risks. The quality and accuracy of accident and incident records also impacted communication across shifts, and therefore effective care to people. The provider had introduced ‘flash meetings’ with a view to promoting better communication and ensure staff were informed of key issues within the service.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. There was a lack of monitoring arrangements in place to identify themes and trends. For example, in relation to people who experienced regular falls and incidents of distress which impacted other people. The poor oversight of accidents and incidents did not ensure people were kept safe, or experienced improved care outcomes.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment. Whilst staff were trained in the Mental Capacity Act 2005, they failed to recognise the need for mental capacity assessments and best interest decisions in relation to covert medicines and medicines prescribed to be crushed and given in water. This meant those medicines were administered unlawfully.

The provider had identified at audits completed in December 2024 and January 2025 that mental capacity assessments and best interest decisions were not in place for security cameras in use in the service. They had not taken sufficient action to ensure these were completed to ensure people who lacked capacity were safeguarded.