Mandeville Grange Nursing Home

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• 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

Well-led – 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 and fair culture.

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 leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulations in relation to governance at the service and notifying us of events that they are required to.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

We identified a lack of transparency and openness in relation to the reporting and escalation of incidents and concerns to external stakeholders including the Local Authority and CQC. This did not protect people from the risk of harm or uphold their human rights and protected characteristics. There was no evidence relatives were kept informed of incidents in line with the duty of candour regulation, which providers are required to do to promote an open and transparent culture.

Some staff described concerns about the culture of the service which did not promote a positive environment to work in. They felt unable to raise concerns directly with the registered manager and found the registered manager to be reactive, as opposed to pro-active. The culture of the service was described as a ‘Closed door to staff with ideas and suggestions from staff not acted on’.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

We identified significant failings in the management and oversight of the service. This impacted on the safety, quality and standards of care provided. The lack of effective management meant policies and procedures were not adhered to, risks to people were not managed and staff were not adequately supported and trained in their roles. This had resulted in a lack of consistent approach to the care and support of people and had led to risks for people using the service.

We received negative feedback from some staff about the registered manager’s ability to manage the service. The feedback indicated staff were not supported, not listened too and this created a culture of feeling demotivated.

Whilst people felt they could speak up and their voice would be heard, staff did not feel listened to. A whistle blowing policy was in place to promote speaking up. However, staff felt unable to speak up with some staff telling us they would be ‘shouted at’. They told us, “Feedback is poor with 90% of issues raised never addressed.” Team meetings took place quarterly however, the minutes of those meetings were brief and reflected very little discussion on key issues affecting people. Staff told us they never had access to the minutes of those meetings.

People who used the service completed a survey in 2024. No issues were identified from those surveys. Staff were not surveyed and therefore staff were not able to raise concerns anonymously and in safe way to promote speaking up.

Staff received supervision. However, some staff felt it was not an opportunity to raise concerns as their confidentiality was not upheld, the supervision form was completed in advance and staff were told to sign it.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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

Whilst auditing systems were improving since the change of the nominated individual in November 2024, previous governance systems were ineffective and had failed to recognise a range of shortfalls in people’s care and the management of the service. As some of these systems remained in use when we inspected issues with the quality of care continued. The registered manager was not working to the provider’s governance and risk policy dated November 2024 to mitigate risks in the service. Records were not accurate, comprehensive assessments were not carried out, risks to people were not managed and people were not safeguarded from abuse. The lack of effective auditing failed to ensure medicines were administered in line with the provider’s policy, accident and incidents were not managed to prevent reoccurrence and appropriate numbers of skilled and competent staff were not provided to safely and effectively meet people’s needs.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

We received limited feedback from professionals in relation to their recent engagement with staff at the service. We saw in records viewed a visiting GP was happy with the care provided to a person. However, there was a failure by the service to recognise and report incidents to the Local Authority Safeguarding Team to enable the local authority to have an effective overview of safeguarding concerns about the service and promote partnership working.

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

The service failed to learn from a choking incident in the service with the measures put in place not embedded in practice or monitored to be assured of learning and improvement. As a result, people remained at risk of choking. Other incidents such as concerns about staff’s practice were not investigated and where the registered manager had agreed increased supervision of a staff member, this had not happened. These practices did not promote learning and improvement, which impacted on people’s safety.