Special protection measures issued at Aylesbury care home rated as 'inadequate' in CQC report

Mandeville Grange Nursing Home was previously rated as ‘Good’ by the CQC, but has seen its rating get slashed after the commission recorded concerns with management and staff’s ability to protect people living in the home.

After carrying out an inspection in January, the CQC has taken special measures to support the residents currently living at the facility.

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 CQC carried out the inspection, after concerns were raised with the ongoings at the facility by a coroner investigating a death at the site. An inquest heard that a woman’s death at the home in 2024, could have been avoided if staff at the home had properly communicated her dietary needs and been adequately trained in emergency response procedures.

Previously, the home had been rated as ‘Good’, but its rating has been downgraded after inspectors assessed how well led, safe, and effective operations are at the home. The CQC did not assess areas of caring and responsive, and those sections are still considered ‘Good’ as a result.

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."

The CQC says the full report will be made available on its website in the coming days.

Mandeville Care Services Limited said: “The management team and all our staff are obviously deeply disappointed by the publication of the CQC report. We have a dedicated team committed to delivering the best possible care and the rating given does not, we believe, reflect the lived experience and positive feedback we receive from our residents and their families.

“We currently have a 9.6 satisfaction rating on Carehome.co.uk which features numerous endorsements from our residents’ families. We are pleased to note that the CQC report itself points out that relatives said they were happy with the care provided and that residents felt safe. In previous CQC inspections the home has been rated as ‘Good’. That said, we have fully taken on board the comments made by CQC in their report. The management team, with the support of all our dedicated staff, has put in place a plan of action for continuous improvement which we are determined will secure a ‘Good’ rating again at the next inspection.

“We have already recruited an interim manager with considerable expertise in the care home sector who is already taking positive steps to ensure that our provisions are not only good, but outstanding, in every aspect of what we do within the home. We are also actively recruiting a long-term replacement to lead the team going forward.

“In addition, we recently commissioned external experts, Care4Quality, to provide a detailed review of our policies and procedures. Care4Quality is a trusted, industry-leading compliance organisation with considerable expertise in the social care sector. We have also been working closely with Fulcrum Care, specialists in care home management issues, to manage the interim turnaround. We have also invested significantly in improved staff training.

“We continue to be committed to providing the very best care and would be happy to talk to any of our residents, family members or carers who have any concerns about any public comment made in respect of this report.”

Editor’s note: This article was updated to include a response from the care home.