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Inspection on 16/05/05 for Mandalay Residential Home

Also see our care home review for Mandalay Residential Home for more information

This inspection was carried out on 16th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Staff was observed interacting with service users and endeavouring to ensure that service users needs are met. Feedback from service users was complimentary towards the management and staff team.

What has improved since the last inspection?

The home has implemented a supervision and appraisal programme for all staff.

What the care home could do better:

The home requires development is assessing the needs of prospective service users, care planning and risk assessment. Medication management, administration and risk assessment.

CARE HOMES FOR OLDER PEOPLE Mandalay Residential Home 10 Julian Road Folkestone Kent CT19 5HB Lead Inspector Penny McMullan, Christine Hastie, Pharmacy Inspector Joesph Harris, Regulatory Inspector Unannounced 16 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Mandalay Residential Home Address 10 Julian Road, Folkestone, Kent CT19 5HB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01303 258095 01303 258095 Stargate Partnership Limited Care Home 24 Category(ies) of Older Persons 24 registration, with number of places Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Mental disorder is restricted to two residents whose dates of birth are 22/06/1944 and 13/7/1949 Date of last inspection 4 October 2004 Brief Description of the Service: Mandalay is registered to provide residential care to 24 older people. At the time of the inspection there were 21 service users in residence two of which are under the age of 65 years. Mandalay is a detached property with single accommodation on two floors with a shaft lift. There are 21 bedrooms with en suite facilities. There is a dinning room, lounge, smoking lounge and large conservatory. There is a well-maintained garden which currently has building materials and rubble due to the ongoing refurbishment of the home. The home is located with access to local shops and the main bus route into Folkestone. The new owner has applied for planning permission to extend the home to provide nursing and residential care for older people and be dual registered with the Commission. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs K.N. Shandrakumar is the Owner/Registered Provider of Mandalay and is proposing to develop the home to become a dual registered care home providing nursing and residential care for older people. However relatives have received a letter informing them that the home is to become part EMI care. Clarification is required by the Commission of the intention of the provider to be considered for registration of the new service. Since the last announced inspection on 21st April 2004, a new roof has been put on but only 8 bedrooms have been refurbished. The home is now looking unkempt and in need of redecoration and refurbishment. Penny McMullan, Lead Inspector, Mrs Christine Hastie, Pharmacy Inspector and Mr Joseph Harris, Regulatory Inspector carried out this unannounced inspection. The inspection commenced at 9 am and Mrs Hastie, Pharmacy Inspector left the premises at 10.15 am, Mr Harris arrived at 11 am. Mrs Hastie reviewed the medication standard and the requirements have been included in this report. Mrs McMullan and Mr Harris continued with the unannounced inspection, which focused on the outstanding requirements of the previous inspections, service user plans, assessment of needs and risk assessment. The home lacks effective management and needs further development to meet the National Minimum Standards. A number of requirements are outstanding from the two previous inspections and revised timescales have been set for compliance. Five service user plans were viewed and five service users were spoken to. Mrs Barbara Russell, Acting Manager, and Sue May, Senior Carer assisted with the inspection. What the service does well: Staff was observed interacting with service users and endeavouring to ensure that service users needs are met. Feedback from service users was complimentary towards the management and staff team. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The lack of written needs assessment for prospective service users puts service users at risk of harm. EVIDENCE: The home does not have clear concise detailed assessment of needs in place for prospective service users. Although the home has a copy of the Care management assessment identifying the needs of the service users the home is not clearly recording how they will meet the needs. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,9 There is no clear consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. The lack of medicine management in the home, inappropriate storage and inadequate systems puts service users at risk of harm. EVIDENCE: The service users plans require development to reflect the assessed needs of the service users. The plans do not contain the information required to meet the service user needs. Risk assessments are not clear and do not provide a safe practice of work. The home needs to amalgamate the two folders, which contain care plan information. The CSCI pharmacist inspector undertook a review of medication handling. Although several service users were partly self-administering medication, there was no evidence that it was within a risk management framework. The lack of assessment and monitoring was found to be affecting residents’ medical care. The provision for storing and handling medicine within the home was far from satisfactory. There was no provision for cold storage and no system for Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 10 transporting medicine safely to service users since the change to blister packs. The Controlled Drug (CD) cupboard was not bolted. Some Inaccuracies were found in record keeping. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed on this inspection. EVIDENCE: Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has a satisfactory complaints procedure in place. The lack of adult protection training put service uses at risk and service users are not protected from abuse. EVIDENCE: The complaints procedure was on display in the entrance hall. Service user spoken to said that they did not have any complaints but would speak to the staff if they had any concerns. An adult protection alert was raised in April with regard to the inappropriate behaviour of one service user. The alert is now closed and the home was issued with a number of recommendations to address regarding the areas of concern. No staff have received training in adult protection. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,25 The lack of progress with the refurbishment does not create a comfortable and safe environment for those living there and visiting. The lack of radiator covers in the dining room puts service users health and safety at risk. EVIDENCE: The décor in the home is now shabby as this is being addressed through the refurbishment plan. The refurbishment has not progressed since the last inspection on 4 October 2005. The Acting Manager stated that work is scheduled to restart in June. The home is required to forward a schedule of works to the Commission together with risk assessments. The garden has rubble, a summer house and shed covered in tarpaulin which will reduce access to service users. There are no current risk assessments in place. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 14 The radiators have not been guarded and were found to be too hot in the dining room. The home must risk assess all radiators in communal rooms and bedrooms until they are guarded through the refurbishment programme. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 Recruitment policies have not been followed resulting in service users receiving care from staff that has not been appropriately vetted. EVIDENCE: One staff file did not contain the appropriate documentation. The home needs to ensure that CRB, POVA checks and two written references are in place for all staff prior to employment. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,36,38 The overall management of the home is not effective resulting in lack of clear concise documentation. Development of some policies and procedures is also required. There are experienced qualified staff in the home however the lack of updates or other mandatory training potentially puts service users and staff at risk. The system for service user consultation is inadequate and there is no evidence that relative and stakeholders views are sought. All staff have received supervision and an annual appraisal. The lack of servicing of bath hoist and mobile hoist puts service users and staff at risk of harm. Fire drills are required to be carried out to ensure the safety of the service users, staff and visitors. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 17 EVIDENCE: There is currently no appointed Registered Manager in the home. This was a requirement from the last inspection to appoint a Manager. The Acting Manager stated that the Registered Provider has advertised for this position but she was not aware of the outcome. Senior carer Susan May is assisting in the office and providing all staff with supervision and appraisal. There is a questionnaire for service users to complete but this is inadequate and relatives and stakeholders have not been consulted. The results were not summarised, published or forwarded to the Commission. The home could not confirm that the bath hoists and manual hoist had received a service. The lift was serviced in April. The Acting Manager said that the contractor who services the lift also looked at the hoists, however there was not evidence to confirm this information. The home must have the hoists serviced as soon as possible and is required to fax the Commission with the certificates of servicing or when the hoists are to be serviced. All other checks with regard to the servicing of equipment have been carried out. The home must carry out risk assessments on the hot water supply to hand wash basins in service users room. The Acting Manager stated that when the weekly fire testing takes place the staff all report to the front entrance however there is no record of a fire drill taking place. The home must ensure that fire drills are carried out and recorded. Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 1 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 1 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x 1 x 2 x 1 Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 19 yes Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Sch 3 (1) (a) Requirement To ensure that the home carries out detiled assesments for prospective service users and idenfies how to meet the needs of the service user Service user plans to reflect the identified needs of the service user, Risk assessments to provide a safe practice of work. This was an outstanding requirement from the two last inspections, timescales 31/7/04 and 31/12/04 All self-administration is assessed and takes place within a risk management framework Self administration is monitored and records kept as appropriate There are clear, accurate records of all medicines received, administered and leaving the home Medicine storage is reviewed and improved All keys are kept securely There is an appropriate means of transporting medicine safely to service users Timescale for action 31/6/05 2. 7 15, Sch 3, 13 Revised 31/6/05 3. 4. 5. 9 9 9 13 (4)(c) 13 (2) 13 (2) 15/7/05 31/7/05 31/5/05 6. 7. 8. 9 9 9 13 (2) 13 (2) 13 (2) 31/10/05 31/5/05 31/7/05 Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 20 9. 10. 11. 12. 13. 9 18 19 30 33 18 (1) (a) 13 23 18 24 14. 15. 36 38 18 13 16. 17. 30 12,18 All staff administering medicine are competent To provide staff with Adult Protection Training To provide the Commison with a detilaed schedule of wrok together with risk assessments To provide staff with risk assessment and care planning training To develop a questionnaire re quality assurance, publish and forward results to the commission. Survey to include relatives and other stakeholders. This was an oustanding requirment from the last two inspections, timescale 31/7/04, and 31/12/04 To ensure staffy carrying out supervision and appraisal are trained to do so To ensure all hoists are serviced. To update and provide all staff with mandatory training. This was an outstanding requirment from the last two inspections, timescale, 31/7/04 and 31/12/04 To carry out and record fire drill. This was an oustanding requirement from the last inspection timescale 31/12/04 To risk assess hot water supply to hand wash basins in service users rooms To appoint a Registered Manager 31/7/05 31/10/05 31/5/05 31/6/05 Revised timescale 31/6/05 31/6/05 Revised timescale 31/6/05 Revised timescale 31/6/05 Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 21 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 4 26 25 Good Practice Recommendations Provide staff training in dementia and mental health needs To review saluicing facilities To provide an action plan with timesclaes to ensure pipework and radiators are guarded or have guaranteed low surface temperature Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 22 Commission for Social Care Inspection 11th Floor, International House, Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mandalay Residential Home H56-H05 S56632 Mandalay V226362 160505 Stage 4.doc Version 1.20 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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