This inspection took place on 3 and 9 May 2018. Both days of the inspection were unannounced, which meant that the staff and provider did not know we would be visiting.

Mandale Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service provides personal care for older people and older people living with dementia. The home is a detached 57 bed purpose built care home in Stockton. It is set out over two floors. At time of our inspection there were 41 people using the service.

When we inspected the service the manager was going through the process of becoming a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered person’s'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

During our last inspection in October 2016 we identified gaps in people’s records. At this inspection we found that there were still omissions in recordings. The new management team had started to complete regular audits, however quality assurance processes had not always highlighted the inconsistent record keeping and recording errors which meant some actions had not been addressed in a timely manner.

This is a breach of Regulation 17, Good governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

Whilst general risk assessments covering areas such as manual handling were in place and regularly reviewed health based risks to people were not always clearly identified and evaluated in care records. Medicines were not always managed safely. There were some gaps in medicine records. There was no record available of staff having undertaken training to take people’s blood sugar readings safely.

This is a breach of Regulation 12, Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

At the last inspection we noted that some Mental Capacity Act Assessments were not decision specific. Since the last inspection some documentation had been completed in this area. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. However further work was needed to ensure all decision specific mental capacity assessments and best interest’s decisions were in place when people lacked capacity. We have made a recommendation about the recording of decisions taken in people’s best interest.

The environment was maintained, however during our visit we identified some issues with the building including a fault with the fire panel which was addressed during our second visit. Equipment checks were undertaken to help ensure the environment was safe. Emergency contingency plans were in place. Infection prevention and control practices were followed.

Policies and procedures were in place to protect people from harm such as safeguarding and whistleblowing polices. Staff knew how to identify and report suspected abuse. People and their relatives felt the service was safe.

There were suitable numbers of staff on duty to ensure people’s needs were met. Safe recruitment practices were in place. Pre-employment checks were made to reduce the likelihood of employing staff who were unsuitable to work with vulnerable people.

The new manager had ensured that staff were scheduled to have or had received training to be able

This inspection took place on 24 October and 1 November 2016. Both days of inspection were unannounced which meant the registered provider and staff did not know that we would be attending.

We previously inspected the service on 13 and 14 November 2014 and found that the service was not meeting all of the regulations which we inspected. We found the service was not meeting the regulations for consent to care and treatment and good governance. This was because the service did not have suitable arrangements in place for obtaining consent. The service had not been following the principals of the Mental Capacity Act 2005 and this had not been picked up by the quality assurance measures in place at the time. There were also gaps in the quality assurance systems in place at the service. We noted that audits had regularly highlighted the same areas for improvement and actions plans had not been put in place following these audits. The registered manager was not given feedback following these audits which meant they had been unable to make the changes needed.

After the inspection on 13 and 14 November 2014, the registered provider supplied an action plan to show us the action they planned to take to improve the quality of the service.

Mandale care home is registered to provide accommodation for people who require personal care, treatment of disease, disorder and injury and diagnostics and screening for up to 57 older people including people living with a Dementia. At the time of inspection there were 46 people using the service who were supported by 39 staff, of which 28 were care staff. The service was located in a residential area within its own grounds and had on-site parking. The service was located close to local amenities and a short distance from the town centre.

The registered manager had been registered with the Commission since 13 January 2013. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection, we could see that the service had listened to the feedback provided to them during the last inspection and had made improvements to the quality of the service.

Staff showed they understood the procedures which they needed to follow if they suspected someone was a risk of abuse. Staff were able to discuss the types of abuse which people could be at risk from and how they could help to minimise these risks. All staff spoken with told us they would not hesitate to whistle blow [tell someone such as the registered manager] if they needed to.

Risk assessments were in place regarding people's specific needs and for the day to day running of the service. These were fully completed and had been regularly reviewed. Staff understood the importance of these to keep themselves and people using the service safe.

Health and safety certificates were up to date and showed measures were in place to ensure the safety of people and staff.

All staff had a Disclosure and Barring Services check in place. DBS checks help employers make safer decisions and prevent unsuitable people from working with vulnerable client groups. People and staff told us there were enough staff on duty throughout the day and night to care for them safely. Two relatives thought staffing levels could be increased. We could see staffing levels were regularly monitored.

People received their prescribed medicines when they needed them. From our observations, we could see that people were supported to take them and people were given the time they needed with their medicines.

Staff told us they were supported during their induction period and records confirmed this. We saw staff shadowed more experienced staff whilst they became familiar with people who used the service

We found that care plans were in place for people who lived at Mandale Care Home. These included risk assessments to enable staff to provide care and support to meet people's individual needs and they were reviewed on a regular basis to ensure that they were up to date.

We saw that meals provided were varied, well presented and the menu was discussed with people who lived in the home to ensure they had a choice of different foods. Specific nutritional requirements were catered for and people's weight was monitored.

The home was clean and well maintained. There were policies in place and training was provided to support people to manage and prevent infection throughout the home. Infection control 'champions' were appointed to ensure that policies were adhered to and to communicate any changes with staff.

Staff were supported to undertake training, had regular supervision, appraisals and staff meetings. Staffing levels were reviewed to ensure that the needs of people living in the home could be met.

There was a complaints procedure in place and people we spoke with including relatives and staff understood how they would make a complaint or support someone who lived at Mandale Care Home to make a complaint. Relatives said that they felt confident to approach staff if there was anything they were not happy with.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

During our visit we found that people who used the service experienced care and support that met their needs and protected their rights. This care and support was delivered by suitably qualified, skilled and experienced staff who worked in co-operation with other healthcare providers and professionals.

We found that people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

People who lived at Mandale Care Home were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

We spoke with one person who told us that they had visited three homes in the local area before deciding to move to Mandale. They said, "We were welcomed immediately and my gut instinct was that this was where I wanted to be, and it was right."

Another person told us that the staff were very attentive, they said, "They can't do enough for you, I never have to press my buzzer they are always around."

People who use the service and relatives are happy with the service provided at Mandale Care Home. In the latest satisfaction survey conducted by the home, there were no negative comments made and good to high levels of satisfaction expressed by service users. People liked the homely atmosphere and the friendly, caring practices of staff. They felt they were well respected by staff who acknowledged and understood their individual needs and wishes. They felt safe and found that they could talk easily to staff about any concerns. They found management to be approachable and helpful. They liked the range of activities and social events on offer. They enjoyed the meals and felt happy with the quality of the catering and choices available. They were confident that their health care needs were being well met, including the arrangements for their medicines and access to healthcare professionals/services. They felt they were consulted about all important matters

We inspected Mandale Care Home on 13 and 14 November 2014. This was an unannounced inspection which meant that the staff and provider did not know that we would be visiting. We last inspected the service on 6 November 2013 and found the service was not in breach of any regulations at that time.

Mandale Care Home is registered to provide personal care and accommodation, diagnostic and screening procedures and treatment of disease, disorder or injury, for up to 57 older people, some of whom may be living with a dementia. At the time of our inspection visit the home had 13 vacancies. The service is provided by TL Care Limited which is operated by the Hillcare Group. The home is purpose built and is set up over two floors, accessible by both stairs and a passenger lift. The ground floor offers residential care with the first floor offering dementia care.

The registered manager had been registered with CQC since January 2013. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the time of the inspection we found that the home was not providing nursing care to people who lived at the home. The registered manager confirmed that the home had not provided nursing care for a number of years. We discussed with the registered manager the importance of ensuring that the service held accurate registration in relation to regulated activities and advised them of the need to apply to deregister the regulated activities that they were no longer carrying on.

Care records we looked at demonstrated that the needs of people who used the service were subject to initial and on-going assessment. We saw that these assessments accurately captured the needs of people and were used to plan and deliver effective and appropriate care. Where appropriate risk assessments were completed, identifying risks and the measures in place to ensure that people were protected from the risk of harm. We saw that where appropriate, for example where people’s assessed care needs had changed, staff made referrals to other healthcare professionals to ensure the correct level and type of care could be delivered.

Our observations over the two days demonstrated that, in the main, people were supported by sufficient numbers of staff. We saw that staff were respectful of people when they delivered care and support and acted in accordance with the wishes of individuals. On the first day of the inspection we did raise concerns with the registered manager and the regional manager about the chaotic atmosphere over lunch time on the first floor and the negative impact that this had on the mealtime experience for these people. On the second day of the inspection we were informed by the registered manager that the usual lunchtime routine had been amended and from our observations we saw that staff were more visible, people who used the service were calm and there was a very relaxed atmosphere.

People we spoke with told us that they felt safe living at the service. They told us that they felt they received good care and that the staff were very kind and respectful. Staff spoke very confidently about the procedures they would follow to take action to ensure the safety of people if they suspected someone to be at risk of harm or abuse.

Staff did not understand the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards which meant they were failing to work within the law to support people who may lack capacity to make their own decisions.

Appropriate checks of the building and maintenance systems were undertaken to ensure risks to people’s health and safety were minimised.

We looked at staff employment files and found that they were subject to rigorous pre-employment checks before they commenced work. When we spoke with staff they informed us of the checks that were carried out and the induction and training process they undertook when they took up employment. Staff told us that they were always completing training and that they felt well supported. From a review of training records we found this to be the case.

Staff we spoke with spoke with knowledge about the care needs of people that they helped to support and care for. We found that the staff knowledge of people’s needs was corroborated by care records and from observations we carried out.

We found that people who used the service were provided with information about how they could raise any concerns and complaints as necessary. We found people’s concerns were responded to appropriately by the registered manager and there were systems in place to enable the service and the provider to learn from complaints and incidents.

The service had a process for monitoring and assessing the quality of the service provision but we were unable to assess its effectiveness due to issues being repeatedly identified and highlighting a failure to produce action plans to address those issues.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we took at the back of the full version of this report.