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Inspection on 02/06/09 for Mandalay

Also see our care home review for Mandalay for more information

This inspection was carried out on 2nd June 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People live in a home which is decorated, furnished and maintained to a high standard. Individual people’s rooms are spacious, comfortable and personalised. The home is clean, tidy and odour free. There is a formal assessment process in place to ensure that prospective people admitted to the care home are assessed prior to admission. Care planning processes within the home are detailed and comprehensive. Risk assessments are devised for all areas of assessed risk and people are actively encouraged to take risks as part of an independent lifestyle. People who live at the care home are supported by appropriate numbers of staff on duty. Rapport between staff and people who live at the care home were observed to be positive and it was evident that staff, know the needs ofMandalayDS0000073022.V375657.R01.S.docVersion 5.2the individual person who lives there. Staff, are provided with appropriate opportunities for training and development. Staff, receive regular supervision. In general medication practices and procedures for the safe administration of medication were observed to be satisfactory. Since the service opened, there have been no complaints and/or safeguarding referrals. A good range of activities both ‘in house’ and within the local community are provided so as to ensure that people have their social care needs met.

What has improved since the last inspection?

This is the home’s first key inspection since being newly registered with us in October 2008.

What the care home could do better:

Where a variable dose of medication is to be given, the specific dose administered must be recorded on the Medication Administration Record (MAR). Whilst we recognise that staff, are assessed as to their continued competence to administer medication, the frequency of these should be reviewed. Where restraint is used, restraint records must be detailed and comprehensive so as to ensure people’s safety and wellbeing.

Key inspection report CARE HOME ADULTS 18-65 Mandalay 13 Bridge Street Witham Essex CM18 1BU Lead Inspector Michelle Love Key Unannounced Inspection 2nd June 2009 10:25 02/06/09 1 Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mandalay Address 13 Bridge Street Witham Essex CM18 1BU 01376 520 280 01376 509 021 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Voyagecare.com Voyage Limited Mrs Mary Grant McIlvaney Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 N/A Date of last inspection Brief Description of the Service: Mandalay is a new care home for 6 young adults who have a learning disability. Mandalay is owned and managed by Voyage who are a large national provider of registered care services, for adults with a learning disability and/or physical disability. The home is positioned slightly back from the main road in Witham, Essex. There is a large parking area to the front of the home, with marked parking spaces including disabled spaces. The building was originally a public house that has been extensively refurbished to a very high standard. The home consists of 6 single rooms with an en-suite wet room, on both the ground and first floors. The communal areas consist of a large lounge, dining room, activity room and large kitchen. None of the rooms on the first floor would be suitable for people who have a physical disability as there is no passenger lift. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection. The visit took place over one day by one inspector and lasted a total of 6 hours, with all key standards inspected. This was the service’s first inspection since being newly registered with us in October 2008. Prior to this inspection we requested the management team of the home to complete an Annual Quality Assurance Assessment (AQAA). This is a self assessment document, required by law, detailing what the home does well, what could be done better and what needs improving. At the time of writing this report we had not received the completed document, although this had been requested on 2 occasions. As part of the process a number of records relating to the people who live at Mandalay, support staff and the general running of the home were examined. A full tour of the premises was undertaken, the resident, support staff on duty and the deputy manager were spoken with and their comments are used throughout the main text of the report. Following the site visit, surveys for support staff were forwarded to the home for distribution and for people to complete and return to us. We received 8 staff surveys and where comments have been recorded, these have been incorporated into the main text of the report. Feedback of the inspection findings, were given as a summary to the deputy manager. The opportunity for discussion and/or clarification was given. What the service does well: People live in a home which is decorated, furnished and maintained to a high standard. Individual people’s rooms are spacious, comfortable and personalised. The home is clean, tidy and odour free. There is a formal assessment process in place to ensure that prospective people admitted to the care home are assessed prior to admission. Care planning processes within the home are detailed and comprehensive. Risk assessments are devised for all areas of assessed risk and people are actively encouraged to take risks as part of an independent lifestyle. People who live at the care home are supported by appropriate numbers of staff on duty. Rapport between staff and people who live at the care home were observed to be positive and it was evident that staff, know the needs of Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 6 the individual person who lives there. Staff, are provided with appropriate opportunities for training and development. Staff, receive regular supervision. In general medication practices and procedures for the safe administration of medication were observed to be satisfactory. Since the service opened, there have been no complaints and/or safeguarding referrals. A good range of activities both ‘in house’ and within the local community are provided so as to ensure that people have their social care needs met. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who come to live at Mandalay can be confident that their needs will be assessed and that they will be provided with up to date information about the service, which will enable them to make an informed choice about where to live. EVIDENCE: Mandalay is a new care service for young adults who have a learning disability and/or physical disability. At the time of the site visit, there was one young person living at the care home and another person had recently been assessed as to their suitability to live at Mandalay and was undertaking periodic visits to the care home as part of their transition. Records showed there is a formal pre admission assessment format and procedure in place, so as to ensure that the management and staff team are able to meet the prospective resident’s needs. Records showed that in addition to the formal assessment procedure, supplementary information is provided from the person’s placing authority and other interested parties. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 9 At this site visit, the care file for the young person admitted on a permanent basis and the person awaiting admission were examined. Records showed that a detailed and comprehensive pre admission assessment had been completed for both people, clearly detailing their specific care needs and the rationale for the referral. Records also showed that the assessment process included the young person’s family and other professionals where appropriate. Each pre admission assessment was also noted to include recommendations for the care plan, risk assessments to be prioritised and specific training requirements for staff. All 8 staff surveys returned to us recorded that staff are given sufficient information about the needs of the individual people they support. Records showed that both people were given the opportunity to visit the care home and the transition period had been thoughtfully planned and included staff from Mandalay visiting the young person’s previous and/or current placement. We were advised by the deputy manager that the length of the transition period varies, according to the person’s needs, information from other agencies, information from the person’s family and the progress of subsequent visits to Mandalay and their current placement, if appropriate. A copy of both the Statement of Purpose and Service User’s Guide was readily available. The care file for the permanent person admitted to Mandalay recorded both documents being given to the young person’s parents. The Service User’s Guide is compiled in both a written and pictorial format. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the care home can be assured that a plan of care, which identifies their care needs and how these are to be met will be devised. EVIDENCE: There is a formal care planning system in place to help staff identify the care needs of individual people and to specify how these are to be met by staff who work in the care home. The care file for the young person admitted to the care home was examined. The support plan included core subject areas relating to communication, medication, dietary needs, social care needs, physical health, financial information, personal care, mobility, social skills, relationships, daily living skills and behavioural issues. All areas were seen to be detailed, comprehensive and person centred and included the person’s assessed need, Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 11 short term and long term goals, their strengths and weaknesses and guidelines for staff as to how to deliver support. As well as the above, the support plan included personal information about the young person, professional support networks, their preferred daily routine, personal preferences, likes and dislikes and interests and hobbies. It was evident from reading this young person’s file that any new member of staff once having read this, would have a good idea about the person’s care needs and how they like to be supported. The care file also included comprehensive risk assessments for all areas of assessed risk. Risk management is proactive in addressing safety issues whilst supporting the person to take responsible risks as part of their lifestyle. Where there are limitations these are clearly recorded and the decisions made with the agreement of the person’s representatives. Each support plan was observed to have been signed by the young person’s representative and support staff, sign both the support plan and risk assessments to say they have read and understood the information recorded. A record of how the person spends their day and staffs involvement is recorded each day. Records showed that the young person is supported and offered opportunities to participate in the day to day running of the home. For example records showed that the young person on occasions makes their own breakfast, is assisted by staff to keep their bedroom and bathroom clean and tidy, assists staff with the weekly food shop and puts away the shopping. There is a key worker system in place at Mandalay and a key worker has been assigned to the young person. The young person was clearly aware as to who their key worker was and there was a good rapport/relationship observed between the two of them. Monthly and weekly key worker reports are compiled, which provide a summary of the person’s progress and any significant events and/or incidents that have taken place. All reports were seen to be detailed and comprehensive. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 14, 15, 16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the care home can expect to have their social care needs met and to receive a varied diet. EVIDENCE: The support plan clearly recorded the young person’s personal preferences in relation to social activities, interests and hobbies. A planned weekly schedule of activities is devised, however we were advised by the deputy manager that this is flexible, so as to take into account the person’s preferences as to whether or not they wish to undertake a particular activity, their behaviours on any given day, weather conditions etc. The support plan also recorded risk assessments for each activity undertaken e.g. swimming, going to the park, travelling in the vehicle, going shopping and these were seen to be detailed. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 13 There is a folder in the manager’s office detailing activities and/or events within the local community. Records showed the young person spends every other weekend with their family and whilst at Mandalay has enjoyed going for walks with support staff, going out in the home’s vehicle, watching DVD’s, listening to music etc. Although the person when asked was unable to state whether or not they had enjoyed the above activities, they showed no signs of unhappiness to the activities provided. On the day of the site visit, the person was observed to go for a walk and after the inspection it was planned for them to go to Maldon in the vehicle and to have a fish and chip supper. Information relating to the person’s personal food and drink preferences were recorded and there was a support plan in place relating to their dietary needs. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured they will have their healthcare needs met in a way that they choose. EVIDENCE: People who live at Mandalay have access to a range of healthcare professionals and services as and when required e.g. GP, Consultant Psychiatry, Dentist, Optician, Chiropody, Home Assessment and Treatment Service (HATS Team) etc. A healthcare folder is devised for each young person and individual records are maintained for each professional and/or service, detailing the date of the appointment, details of the appointment and outcome, next scheduled date and the names of staff involved. As part of this site visit medication practices and procedures were examined. Medication was observed to be stored securely and medication storage temperatures are monitored each day and record these as satisfactory and within recommended guidelines. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 15 We looked at medication and medication records for the young person living at Mandalay. In general terms medication records were seen to be satisfactory, however where a variable dose of medication is prescribed, the specific dose administered must be recorded. Where medication is prescribed as PRN (as and when required) PRN protocols had been compiled. The home carries out weekly medication audits so as to highlight any shortfalls and deficits. Medication is only given by trained staff and there was evidence of recent training. Also there was evidence to show that some staff had received an assessment as to their continued competence to administer medication. The deputy manager stated that these are conducted every 6 months. Whilst we recognise this as good practice, further consideration should be looked at to undertake the above task more frequently, for example every 3-4 months. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect their concerns to be listened to and dealt with as they would wish and that they will be safeguarded by staff knowledge and supporting policies and procedures. EVIDENCE: There is a corporate complaints policy and procedure in place. We were advised that since the home has opened there have been no complaints. The young person was unable to clarify at the time of the site visit, if they know how to make a complaint or who they would talk to, however we are assured that the staff team and the young person’s family would advocate on their behalf should the need arise. There are both corporate and local safeguarding policies and procedures in place and these include physical intervention policies and procedures. No safeguarding referrals have been made since the home opened. All staff working at the care home had up to date training pertaining to safeguarding. Staff were able to demonstrate a good understanding of safeguarding procedures. However we are aware there have been 2 occasions whereby the young person was physically restrained by staff as a result of their challenging/inappropriate behaviours. The deputy manager was advised that further development of the Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 17 records is required to ensure that they include the type of restraint used, the timeframe of the restraint used, the names of staff involved and specific information as to what preceded the incident and the outcome. On inspection of staff training records, all but 2 people have undertaken NVCI training (Non Violent Crisis Intervention). Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Mandalay can expect to benefit from a home that is comfortable, homely, safe and which meets their needs. EVIDENCE: The home consists of 6 single bedrooms on both the ground and first floors. All rooms have an en-suite wet room which is fitted with a shower however should anyone wish to have a bath fitted instead this can be arranged. One young person’s bedroom was examined and this was seen to be personalised and individualised to meet their needs and to suit their personal preferences. Communal areas consist of a large lounge, dining room to seat 12 people, spacious activity room and domestic style kitchen. All areas of the home were observed to be decorated and furnished to a very high standard. On the day of the site visit the home was observed to be clean, tidy and odour free. The Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 19 laundry area is sited to the rear of the property and is equipped with an industrial washer and dryer and there is a sluice room next door. The garden is accessible for service users and garden table and chairs has been purchased. There is, a small staff sleeping in room with en-suite toilet and shower facilities on the first floor. The deputy manager advised that all maintenance works are referred to a central call centre and external contractors are used by the organisation. As of the end of June 2009, a gardener will be employed for 1 day a month. Records of routine safety checks were requested to ensure a safe environment was maintained for residents and staff. Current safety inspection certificates were available in relation to the fire alarm, electrical installation and gas safety record and food hygiene. There was a fire risk assessment and plan for the home, fire alarms and emergency lighting were tested weekly and there was evidence that regular fire drills are conducted. The home was visited in February 2009 by the Fire Officer and was deemed to have attained a satisfactory standard of fire safety. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the care home can expect to be cared for by a staff team who are skilled and competent to look after them and meet their needs. EVIDENCE: At the time of the site visit there was 1 permanent person living at Mandalay and another person was periodically visiting the care home as part of their transition. We were advised by the senior support worker that currently there are 2 people on shift between 07.00 a.m. to 14.00/14.30 p.m. and 14.00 p.m. to 21.00/21.30 p.m. each day. At night 21.00 p.m. to 07.00 a.m. there is 1 waking night member of staff and 1 sleeping in person. The person managing the care home in the interim whilst the manager is off sick receives a small number of shifts which are supernumerary to the above figures. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 21 The rota reflected accurately the staff on duty on the day of the site visit. We requested 4 weeks staff rosters and these demonstrated that the above staffing levels had been met. Care must be taken to ensure that the full names of staff working at the care home are recorded on the staff roster. We also advised that where individual service users are funded to have additional staff on duty for one-to-one provision, the person providing this should be recorded on the staff roster each day. We were advised by the senior support worker and deputy manager that 4 new members of staff have been newly recruited and currently they are waiting for all checks to be completed before they can commence working at Mandalay. The staff files for the manager and 3 staff were reviewed to examine if appropriate checks had been undertaken prior to employment. Records showed that the majority of records as required by regulation had been sought, however there was no recent photograph for one person, the picture on one person’s proof of identification (passport) was not decipherable, there was no proof of identification on the manager’s file and not all of the manager’s application form was available. Records showed that all staff had received an induction. One staff survey recorded, “The staff have a very good induction and are helped by fellow staff to learn the paperwork. The care plans are easy to follow and updated as needed”. We looked at 3 members of staff’s training records. Records showed that all staff receive relevant training in both core and specialist subject areas. Training is provided by external trainers and through the organisations computer software programme. Staff spoken with confirmed the organisation is proactive in ensuring that they have appropriate and up to date training. Training includes health and safety, infection control, food hygiene, first aid, safeguarding, administration of medication, epilepsy, introduction to learning disabilities, total communication, report writing, risk assessments and person centred planning. One staff survey recorded, “The training and support we are given is very good and If I have any worries then I have plenty of support”. We were advised that currently 3 staff have attained NVQ Level 2 and the deputy manager has NVQ Level 3. Of 4 staff files examined, all were noted to have received a supervision and an appraisal. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Mandalay can expect the care home to be run in their best interests. EVIDENCE: At the time of the site visit the registered manager was off sick and in the interim the home is being managed by the deputy manager. We were advised by the organisation of the above through Regulation 37 notifications. The deputy manager has extensive experience in working with people who have a learning disability and/or physical disability and they have worked within a care field setting for the past 14 years. Staff spoken with confirmed that the interim management arrangements are satisfactory and that it is “business as usual”. Staff, were complimentary about both the manager and the deputy manager. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 23 One staff survey recorded, “The management interact with all staff and are approachable and work with everyone for the service users wellbeing”. Another survey recorded, “The home runs a relaxed friendly environment whilst keeping to the correct standards. The home provides a caring service”. The deputy manager stated that the ethos of the service is to “work with peoples’ existing skills, to promote independence and to develop peoples’ peer group networks”. The deputy manager stated there is a committed staff team at Mandalay who work well together for the benefit of the people who live within the service. The deputy manager is aware that the dynamics of the home could change significantly as new people are admitted to Mandalay, however she feels that although there may well be certain ‘challenges ahead’, she is confident that staff will continue to do their best and to meet individual’s care needs. We were advised by the deputy manager that there is a corporate quality assurance system in place to seek the views of the people who live at Mandalay, staff team members, peoples’ representatives and other interested parties, as to the quality of the service provided. As there is currently only 1 person living at Mandalay, the above process has yet to be implemented. Monthly Regulation 26 visits to Mandalay are completed by a representative of the organisation and a report compiled. An AQAA was requested in December 2008 however we recognise that at that time there were no people living at the care home. The organisation contacted us and told us this and another request for an AQAA was made by us in February 2009. At the time of the site visit, the document had not been returned to us and when questioned the deputy manager advised us that as far as she was aware the AQAA had been completed by the registered manager. We requested that this be forwarded to us, however at the time of writing this report we had not received the documentation. No health and safety issues were highlighted as part of this site visit and on inspection of the home’s policies and procedures folder appropriate health and safety policies were in place. Staff stated that they know where these are located and can access these at any time. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 3 X Version 5.2 Page 25 Mandalay DS0000073022.V375657.R01.S.doc Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement Where a variable dose of medication is to be administered, the specific dose administered must be recorded on the MAR record. To ensure people’s safety and wellbeing. Where restraint is used, records must clearly record the type of restraint used, the timeframe for restraint, the names of staff involved and specific information as to what preceded the incident and the outcome. To ensure that people’s safety is maintained. All records as required by regulation are in place. To ensure there is a robust recruitment procedure in place and that people are safeguarded by the home’s procedures. Where an AQAA has been requested, this must be completed and returned to us by the due date. Timescale for action 03/07/09 2 YA23 17(1)(a), Schedule 3 03/07/09 3 YA34 19 03/07/09 4 YA39 24 03/07/09 Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA20 YA33 YA33 Good Practice Recommendations Consider reviewing the frequency of medication competency assessments for staff who administer medication. The full names of all staff who work at the care home must be recorded on the staff roster on any given day. Where people who live at Mandalay receive additional funding for one-to-one staffing, this should be highlighted on the staff roster for auditing and commissioning purposes. Mandalay DS0000073022.V375657.R01.S.doc Version 5.2 Page 27 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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