Mandale Care Home

On this page

• 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, fair culture. At our last assessment we rated this key question requires improvement and identified regulatory breaches in relation to good governance and failure to notify the CQC of required incidents. At this assessment they were no longer in breach of the regulations. The rating has remained requires improvement as improvements were needed with the provider’s quality monitoring system. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (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 shared vision based on honesty and openness. Staff felt able to share their thoughts and ideas and said they were listened to. The registered manger explained they were looking at events to support different cultural festivals. The provider had a dedicated staff member who provided training for overseas staff before they worked in the home. This support was ongoing and followed up in staff meetings.

The registered manager and regional manager had an inclusive approach. Staff commented they were visible, supportive, knowledgeable, open and honest. They were responsive to feedback during the assessment and took action to make improvements when needed.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

Improvements had been made to governance systems and there was improved oversight. Some shortfalls found during the assessment had not been picked up on during audits. For example, care records for one person lacked specific support strategies which led to inconsistent support. Shortfalls in relation to IPC and medicines management had not been identified. This was shared with the management team who took immediate action and offered assurances improvements would be embedded and sustained. The registered manager was submitting statutory notifications to the CQC as required.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The registered manager focused on learning and improvement. They had gained the trust and support of the staff team and together were working to ensure people received safe care and support. Learning had taken place since the last inspection in relation to safeguarding, governance procedures and submitting required notifications to the CQC.