Archived: Mandalay Care Home

Updated 3 August 2018

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, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

We used information the registered persons sent us in the Provider Information Return. This is information we require registered persons to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We also examined other information we held about the service. This included notifications of incidents that the registered persons had sent us since our last inspection. These are events that happened in the service that the registered persons are required to tell us about. We also invited feedback from the commissioning bodies who contributed to purchasing some of the care provided in the service. We did this so that they could tell us their views about how well the service was meeting people’s needs and wishes.

We visited the service on 18 and 19 June 2018 and the inspection was unannounced. The inspection team consisted of one inspector.

We met and spoke with 13 people who lived at the service, we observed some people’s care, the lunchtime meal, some medicine administration and some activities. We spoke with three people’s relatives. We inspected the environment, including the laundry, bathrooms and some people’s bedrooms. We spoke with two senior carers, two care assistants and some housekeeping staff as well as the deputy manager, registered manager, service administrator and operations manager.

In addition, we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not speak with us.

During the inspection we reviewed other records. These included staff training and supervision records, four staff recruitment records, medicines records, care plans, risk assessments, accidents and incident records, quality audits and policies and procedures.

We displayed a poster in the communal area of the service inviting feedback from people, relatives and staff. Following this inspection visit, we did not receive any additional feedback.

Updated 3 August 2018

This inspection took place on 18 and 19 June 2018 and was unannounced.

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 Care Home accommodates up to 46 people in one building including the use of an attached small dementia suite called the Sunflower unit. There were 40 people using the service, 10 people living in the Sunflower unit and 30 people in the main building. People cared for were all older people; some living with dementia and some who could show behaviours which may challenge others. People had a range of care needs, including diabetes. Some people needed support with all personal care and some with eating, drinking and their mobility needs, while other people were more independent.

Bedrooms are situated over three floors and can be accessed by the passenger lift; the premises are suitable for people with physical mobility problems. People had access to assisted bathrooms and a dining room/lounge/conservatory and enclosed rear garden.

The registered manager worked at the service each day and was supported by a deputy manager. A registered manager is a person who has registered with CQC 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 last comprehensive inspection on 4 and 5 April 2017 the overall rating of the service was, ‘Requires Improvement’. We found there was one breach of the regulations. This referred to shortfalls in the systems and processes intended to check and improve the quality service provided. That inspection also identified other shortfalls about the management of mattresses and equipment intended to help protect people at risk of skin damage. There was also underdeveloped guidance for staff about how to support some people whose behaviours could challenge.

We asked the provider to complete an improvement plan to show what they would do and by when to improve the key questions of Safe and Well-Led to at least ‘Good’.

At this inspection, improvements in monitoring and resolving problems in the running of the service resulted in sufficient progress to meet the previously breached regulation. However, we concluded that more progress was still needed to ensure these processes were fully embedded so that consistency of records and development of the service was maintained. Previous areas identified as requiring improvement, about mattress equipment and guidance for staff, had suitably improved. However, we identified other areas requiring improvement relating to the safe storage of an oxygen cylinder and some medicine records checks. These were resolved on the day of the inspection.

People were protected from harm by staff who were trained to recognise signs of abuse. Where risks to people were identified, staff acted to minimise them. There were enough staff to meet people's needs and staff were recruited safely. Medicines were stored, given to people as prescribed and disposed of safely by properly trained staff. People were protected from the risk of infection by robust prevention and control measures. Analysis and reflective practice meant lessons were learned when things went wrong.

People's needs were assessed before they moved into the service. These needs were met by staff who had the skills and knowledge to deliver effective support. People were supported to eat and drink enough to have a balanced diet, including those with complex health needs. People were supported to have healthier lives by having timely access to healthcare services. People lived in an environment which was suitable for people living with dementia. People were supported to have maximum choice and control of their lives, staff supported them in the least restrictive way and the policies and systems in the service reflected this practice.

People received a service which was caring, they were treated with dignity and respect. Staff were compassionate and caring, this was commented upon positively by people and their visitors. Staff treated people's private information confidentially. People, where possible, made decisions about how their care was provided and were involved in reviews of their care together with people important to them.

Care was personalised to people’s individual needs and preferences. A range of activities were

available for people to participate in if they wished and people enjoyed spending time with staff. Staff knew people's interests and needs well. There was a complaints policy available to people. Staff were open to any complaints and understood that responding to people's concerns was a part of good care.

People and staff were positive about the culture of the service, people and relatives felt the staff team were approachable and polite. The staff team worked with other organisations to make sure they followed current good practice. Maintenance records for equipment and the environment were up to date. Policies and procedures had recently been updated and were available for staff to refer to. Staff said they were encouraged to suggest improvements to the service. Relatives told us they could visit at any time and were always made to feel welcome and involved in their relative’s care. People were supported at the end of their life to have a dignified and comfortable death.

The provider's vision and values were embedded into the service, staff and culture. Governance systems were largely effective in ensuring shortfalls in service delivery were identified and rectified. The provider had sent CQC notifications in a timely manner. Notifications are changes, events or incidents that the service must inform us about.