Mandale Care Home

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• 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 assessment we rated this key question requires improvement and identified regulatory breaches in relation to safeguarding and good governance. At this assessment the rating has changed to good and the service is no longer in breach. This meant people were safe and protected from avoidable harm.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a positive culture, based on openness and honesty. Staff reported concerns which were investigated and reported on. Staff commented on a learning culture, with one staff member saying, “They are helping me to progress and develop.” A relative said, “I am able to complain, and I am confident I would be listened to.”

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.

Effective systems and procedures were in place to protect people from avoidable harm and abuse. People, and their relatives said they felt safe. Staff had attended training and knew how to report concerns, saying they were confident action would be taken. Concerns were reported and investigated with appropriate actions taken. Safeguarding concerns were monitored for learning so the risk of future incidents could be minimised.

Systems were now in place to assess and manage risks. Risk assessments were in place and were person centred. Staff worked together to mitigate risks but didn’t always have a consistent approach. The registered manager took action to address this following feedback.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Safe recruitment practices were followed. The registered manager made sure there were enough staff to meet people’s needs. Some gaps in staff training and support meetings had been identified and improvements were being made. Action had been taken to ensure this was monitored and sustained.

Systems and processes were in place to assess and manage infection prevention and control. However, they did not always detect issues and improve processes. We identified some concerns in relation to cleaning and hygiene which were immediately addressed by the registered manager. Cleaning schedules were also improved following feedback to ensure they detailed the tasks which needed to be completed. The renovation of bathrooms was due to take place in April 2025 which would result in further improvements in infection prevention and control.

People, relatives and staff raised no concerns about medicines management. We identified shortfalls with records relating to the management of time specific medicines; topical medicines, and medicines administered on a ‘when required’ basis. Some medicine stock did not balance with records and a small number of medicines were out of stock which meant it was not always clear whether staff had administered the medicines as prescribed. Following our feedback, management staff took action to address some of the issues identified.