Mandalay

Updated 12 February 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC’s response to care homes with outbreaks of coronavirus, we are conducting reviews to ensure that the Infection Prevention and Control practice was safe and the service was compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place.

This inspection took place on 15 January 2020 and was announced.

Updated 12 February 2021

Mandalay 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. Mandalay accommodates up to six people in a detached house in the centre of Witham. At the time of our inspection there were four people living at the service. Mandalay has an excellent location, close to shops, public transport and other amenities.

At our last inspection, we rated the service good. At this inspection, we found the evidence continued to support the overall rating of good. Although we found there was some room for improvement, there was no evidence or information from our inspection and on-going monitoring that demonstrated serious risks or concerns. As a result, this inspection report is written in a shorter format.

At this inspection, we found the overall rating for the service remained good.

There had been a period of disruption since our last inspection, after the long-standing manager had left the service. However, a new experienced manager had been appointed who demonstrated excellent skills and in the few months they had been at the service, morale had improved and there was a more open, dynamic culture. Improved audits and action plans were in place, which were driving improvements in the service.

Staff were caring and compassionate and treated people as individuals. However, we found staff did not always support people to develop their skills and lead fulfilling lives. Care plans were written in a person centred way but were not easily accessible to people, in line with best practice. We made a recommendation around improving developing information in line with people’s individual communication needs. The provider had not always gathered feedback from people and families. We therefore rated responsive as requires improvement.

There were enough safely recruited staff to meet people’s needs. Risk was well managed at the service and people were protected from abuse. People received support to take their medicines, as prescribed. There were measures to reduce the risk of infection.

There was scope to enhance the decoration and design of the property and gardens, in line with best practice principles. We have made a recommendation about this.

Although staff had not supported people to develop aspirations for the futures, they were skilled at enabling people to make choices about their day-to-day lives. The Care Quality Commission is required by law to monitor how a provider applies the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way. Management and staff met their responsibility under the MCA. Where people were being restricted of their freedom, the manager had taken the necessary actions to ensure decisions were made in their best interest.

Staff knew peoples’ needs well and had the necessary skills to support them. Training had improved and staff felt well supported. Staff supported people to keep healthy and access outside professionals when required. People could choose what they ate and drank, in line with their preferences.

Further information is in the detailed findings below.