The Care Quality Commission (CQC) has rated Mandeville Grange Nursing Home in Aylesbury, Buckinghamshire as inadequate and placed it into special measures to protect people, following an inspection in January.
Mandeville Grange Nursing Home, run by Mandeville Care Services Limited, is a care home providing nursing and personal care for up to 31 people. At the time of this inspection 17 people were living at the home.
The inspection was carried out in response to concerns identified by a coroner following an inquest.
The overall rating for the home, as well as the areas of safe, effective, and well-led have moved down from good to inadequate. The areas of caring and responsive were not part of this inspection and retain their previous rating of good.
Following the inspection, CQC served three warning notices to Mandeville Grange Nursing Home to focus their attention on making significant improvements around people’s care and treatment, staffing, and the management of the service.
The service has been placed in special measures, which means it will be kept under close review by CQC to keep people already living there safe while improvements are made.
Roger James, CQC deputy director of operations in the north, said:
“When we inspected Mandeville Grange Nursing Home, we were disappointed to find a deterioration in the level of care being provided as a result of poor management at the home. We weren’t assured that leaders were managing it effectively, and this put people at risk of harm.
“We found there wasn’t a positive safety culture based on openness and honesty. Leaders didn’t listen to safety concerns or always investigate issues, including concerns about how staff were treating people. They also didn’t ensure lessons were learned following incidents, including one where someone choked, and they didn’t always report incidents to external partners to inform them what had happened.
“Additionally, leaders didn’t have an effective system in place to ensure people were protected from potential abuse, and they had failed to understand their duty to report these to CQC and the local authority safeguarding team. This is unacceptable.
“There wasn’t always enough staff to keep people safe. For example, during our inspection someone fell over in the lounge and the home’s investigation found there hadn’t been enough staff on duty at the time. We also found staff hadn’t been given appropriate training or supervision for their roles to ensure they could safely support people.
“The people living at Mandeville Grange Nursing Home, deserve better and we’ve told leaders where rapid and widespread improvements need to happen. We’ve placed the service in special measures to protect people and won’t hesitate to take further regulatory action if this doesn’t happen.”
Inspectors found:
- Care plans did not include people’s individual needs, preferences, and choices.
- Infection control risks were not identified or addressed. When people had contagious infections, staff did not always follow the right processes to prevent them from spreading.
- Medicines were not always managed safely or given to people as prescribed.
- Quality assurance systems at the home were not always effective.
- Leaders and staff did not always follow the principles of the Mental Capacity Act.
- Staff felt unable to speak up about issues.
- The need for people’s consent was not consistently applied.
However:
- Some people and their relatives spoke positively about the care provided and their access to equipment such as walking aids and call bells.
- People felt able to raise concerns about the home with staff.