Mandeville Grange Nursing 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection, the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, medicines management, staffing levels and training, and their failure to safeguard people.

This service scored 31 (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 have a proactive and positive culture of safety based on openness and honesty. They did not demonstrate they listened to concerns about safety and did not investigate or report safety events. Lessons were not learnt to assist them to identify and embed good practice.

There was no oversight in place for accidents, incidents or safeguarding concerns. Therefore, accidents, incidents and safeguarding concerns were not reported externally, investigated and no measures were put in place to prevent a reoccurrence. For example, people were exposed to continuing risks of injury and there was a continued increase in falls for another person.

Measures put in place following a choking incident at the service were not sufficient to prevent a reoccurrence. The assessment documentation relating to a recent admission to the service did not have the required care plans and risk assessments put in place in a timely manner to ensure staff were informed of risks and could support the person safely to minimize risk of harm to them. We saw staff were not responsive to a person who was at high risk of choking, who was coughing whilst being supported with their meal. The staff member did not alert the nurse in charge as was outlined in the person’s care plan. This placed them at risk of choking and meant learning from the previous choking incident was not embedded in practice.

Some staff told us they were not aware of systems in place to promote learning with staff commenting, "If there are systems in place they have never been relayed to me."

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not work with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Safeguarding systems were not effective. Staff and leaders did not recognise when incidents and events within the service, including poor practice recorded in staff supervision files which met the threshold to be reported to the Local Authority Safeguarding Team to protect people from harm and abuse. A lack of onward reporting was not protecting people or upholding their human rights. The provider completed the safeguarding referrals and CQC notifications in restrospect.

Staff were trained in safeguarding. However, they and the management failed to recognise abuse which meant that training was not effective in safeguarding people. Staff told us, ‘The reduction in staffing levels placed people at risk of abuse, as staff are not able to give people the care and support, they need, with care being rushed when short staffed’. Staff confirmed, they had raised concerns about a person who was at risk of abuse to themselves and others when they were distressed. However, the service had not been pro-active in putting measures in place to mitigate the risk of abuse.

Deprivation of Liberty Safeguards (DoLS) applications were made for people deprived of their liberty and who lacked capacity on their care and treatment, such as the need for the service to be kept locked and secure and use of bed rails. CQC were informed when DoLS applications were approved.

The provider did not work with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people in relation to choking, falls, behaviours of distress, medical conditions, tissue viability, moving and handling and bed rails were not assessed.

Choking risks were not mitigated. A care plan for a person at risk of choking did not make it clear if staff were to assist or observe them with their meal. It was recorded first aid was to commence before an ambulance was called. This had the potential for a delay in the ambulance being called and placed them at risk of choking. In the medicine care plan for a person deemed a high risk of choking on food, it was recorded there was no swallowing problems when taking their medication. In the person’s prescription it was recorded, their medicine was to be crushed and given in water, which was not reflected in their medicine care plan. This had the potential for the person to be exposed to the risk of choking. Staff told us there was a delay in updating care plans and risk assessments, including risks associated with choking which placed people at risk.

Moving and handling risks were not mitigated. In a person’s assessment it was recorded 3 to 4 staff were required for transfers. This impacted other people as staffing levels were not sufficient. On day 2 of our inspection a revised moving and handling assessment indicated 2 to 3 staff were required. In view of the outcome of the 2 different assessments we were not assured by the accuracy of the previous assessment. There was the potential for the person to be injured during moving and handling manoeuvres. The provider took immediate action and had an independent moving and handling assessment carried out, which confirmed 2 staff were appropriate and made other recommendations about the equipment in use and staff’s approach to the manoeuvre.

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

Staff told us the handsets they used to access care plans, risk assessments, daily records and monitoring charts were not fit for purpose. This was because essential buttons were broken, 2 handsets needed frequent battery changes in a 12-hour shift, 1 kept freezing and required frequent restarts and 1 did not take photos. The handsets were held together with tape or an elastic band. The issues with the handsets had been raised in a team meeting in August 2024. Whilst 2 handsets were replaced, the registered manager failed to audit all of the handsets to ensure staff had the required equipment to do their job. Working with equipment that was not fit for purpose did not support the delivery of safe care.



During the inspection we found areas of the service felt cold and observed free standing heaters in use in bedrooms. For 1 person this was placed close to their bed and was a fire risk. No risk assessment was in place to identify and mitigate the risks.

Staff told us the home was cold with the heating system not effective. They told us, “‘The windows blow a gale when they are shut, and the hot water takes a long time to run through warm.” They confirmed this impacted people's personal care and well-being. The provider agreed to carry out a full audit of the temperature, windows and water in the service to ensure people are not exposed to a cold drafty environment or lukewarm water for personal care.

After the inspection the provider confirmed the boiler and pump were replaced with further work scheduled to improve the reliability of the system.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The staffing levels outlined as required on the dependency tool and as confirmed by the nominated individual and deputy manager were not provided. The rotas reviews showed there was 20 out of 30 shifts which were not adequately staffed. Staff told us staffing levels were not sufficient, and this impacted people's care and safety especially in the evenings when 3 carers were on shift. On day 2 of our inspection a person had a fall in the lounge. The provider’s investigation confirmed the staffing levels impacted on the fall as there was not sufficient staff on duty to have oversight of the lounge.

Staff were not suitably trained and competent for their roles. They had completed online training with no evidence practice was monitored to ensure training was embedded in practice. Staff were not assessed or deemed competent for tasks they were undertaking such as catheter and wound care. Staff told us they did not feel suitably trained to support people safely when they were experiencing episodes of distress. Staff were carrying out tasks they were not trained for such as supervision, assisted feeding competencies and moving and handling audits. The service had no designated moving and handling assessor which meant there was no one designated to assess people’s changing moving and handling needs.

Staff told us they were not adequately supported. The records showed staff including the registered manager and deputy manager were not receiving supervision at the frequency outlined in the provider’s policy.

Recruitment practices were safe, and the required checks were completed prior to staff commencing work at the service.

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

Contagious infections were not well planned for and managed. Risk assessments were not in place to mitigate the risks of cross infection. When people had active infections, staff did not always follow infection control practices in relation to the gloves they were wearing. Care plans did not clearly define how to manage infection control for contagious infections.

Whilst staff were trained in infection control, there was no specific training, guidance, or risk assessments in care plans to ensure staff understood the infection control measures they needed to adhere to, to mitigate the risks of cross infection and keep people safe.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Medicine practices were not always safe, and staff were not working to best practice and the providers’ medicine management policy to ensure medicine records were accurate. Medicines were not always signed for on administration and some agency nurses did not use the electronic medicine system. This created a discrepancy between the system balance and the written balance which was not picked up during administration of the medicine. This meant discrepancies in medicine stocks were not noted or addressed in a timely manner to promote the safe management of medicines.

Covert medicines (medicines given in a disguised form without the knowledge or consent of the person receiving them) were not managed in line with the provider’s policy and best practice guidance. A person was prescribed covert medicines with no guidance provided on how these were to be administered. We were told the medicine was crushed and given in yogurt or jam. Another person’s medicine was prescribed to be crushed and given in water. The service had not liaised with the pharmacist as to whether prescribed medicines could be crushed without impacting the therapeutic effects of them. This was not in line with best practice or the providers medicine policy which did not promote safe management of medicines.

Transdermal patch administration records and topical administration medicine records (TMAR) were not in use to record the administration and rotation of a transdermal patch and the application of topical creams. In people’s records we saw there were inconsistencies in where topical creams were applied which meant we were not assured medicine was administered for what it was prescribed for. This was not in line with the provider’s medicine policy and did not promote best practice in medicine administration.