Working at Mandalay

Some serious incidents were not reported to the regulator, so lessons were not always learned properly.

We identified further concern about a potentially life-threatening incident which was not reported to CQC and subsequent hospital admissions which did not result in a notification or safeguarding referral being made.

Eight empty positions mean staff work extra hours and are stretched thin.

The service had eight vacancies at the time of the inspection. This was having an impact on the service. Staff picked up overtime.

Weak oversight from bosses above the manager led to gaps in handling incidents and support for staff.

An underreporting of incidents had resulted in poor provider oversight. We were not assured the governance and oversight were robust.