Inspection on 02/08/06 for Mandalay Residential Home

This inspection was carried out on 2nd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

Other inspections for this house

Mandalay Residential Home 05/08/09

Mandalay Residential Home 15/04/09

Mandalay Residential Home 28/04/08

Mandalay Residential Home 05/11/07

Mandalay Residential Home 14/11/05

Mandalay Residential Home 16/05/05

Mandalay Residential Home 09/11/04

Mandalay Residential Home 20/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mandalay Residential Home 10 Julian Road Folkestone Kent CT19 5HB Lead Inspector Wendy Jones Unannounced Inspection 09:30 2 August 2006 nd X10015.doc Version 1.40 Page 1 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 Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 2 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 DS0000056632.V300352.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mandalay Residential Home Address 10 Julian Road Folkestone Kent CT19 5HB 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) 01303 258095 01303 258095 Stargate Partnership Ltd Mrs Suzanne Yvonne Welsh Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (23) Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. MD is restricted to two residents whose dates of birth are 22/06/1944 And 13/07/1949 14th November 2005 Date of last inspection Brief Description of the Service: Mandalay is registered to provide residential care to 24 older people. The Registered Providers have applied to the Commission for a variation of the registration to increase the number of residents in the home to 39. The home is currently being extended and the whole of the premises is being refurbished and redecorated. There are local shops and the main bus route into Folkestone runs close to the home. The statement of purpose gives information about the service. A copy can be obtained from the home. The most recent inspection report can be seen in the home. Currently the scale of fees is between £303.25 and £356.92. Hairdressing, chiropodist, transport, papers, toiletries and holidays are at an additional charge. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Wendy Jones, Regulatory Inspector, carried out this key inspection. It was carried out over a period of time and concluded with a site visit to the home between 10:00am and 3:00pm on 2 August 2006. A range of evidence has been used to inform this report and judgements have been made based on this evidence. Evidence used includes, concerns, complaints, allegations and other information received, reports of incidents and deaths that have occurred in the home since the last inspection, a tour of the home, inspection of some records, comments received from residents, their relatives, care managers, doctors and other healthcare professionals and discussion with the matron, residents and staff. What the service does well: What has improved since the last inspection? What they could do better: Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 6 Risk assessments are in place for residents, but these still need to be more comprehensive and individual to each resident. They must show the risk that has been identified, what needs to happen to reduce or remove this risk and the outcome that is expected from putting this in place. There is currently no registered manager. A senior member of staff is acting up into this post. A competent, permanent manager who has the qualifications and experience required must be recruited as soon as possible. An application must then be made to the Commission for their registration as manager. The temperatures of the fridge and freezer in the dry store in the basement of the home are not checked and recorded daily. The temperature of all fridges and freezers must be checked and recorded daily to make sure food is kept at the right temperature. It is particularly required for the fridge and freezer in the basement because they are next to the boilers and the room was very warm. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 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 the following standard(s): 1, 3 and 4 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents and prospective residents have the information they need to make a decision about moving into the home. EVIDENCE: This building and refurbishment work is now nearing completion. The acting manager has carried out pre-assessments for four prospective residents who want to move into the home when this is finished. One new resident was moving in that day. These pre-assessments contained assessments from their care managers and comprehensive information about the prospective residents. Specific, individual risk assessments will need to be carried out when they move into the home. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 9 The Statement of Purpose and Service User Guide are to be updated to show the improvements and changes that the refurbishment works have made to the home and the increase in numbers. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 7 - 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ general health and personal care needs are met. However, they could be at risk at times due to a lack of detailed, individual assessments to identify risks. EVIDENCE: Care plans have been improved and now clearly show the needs and goals of the residents and how staff are to help them to achieve these. Risk assessments are in place but these still need to be more comprehensive and individual to each resident. They must show the risk that has been identified, what needs to happen to reduce or remove this risk and the outcome that is expected from putting this in place. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 11 Care plans had been reviewed monthly and daily detailed records were being kept. They also showed when the resident had seen their doctor, or district nurse and of optician, dentist etc appointments. Medication was being stored appropriately and medication administration records were up-to-date and accurate. Risk assessments for residents who take their own medication were seen. Further improvements to the medication room will be made when the refurbishment work is complete. This will include fitting a sink and providing a fridge specifically for storing medication. Staff were helpful, patient and caring and had a good rapport with the residents. Residents said they were very happy there. That the “staff are very helpful and supportive” and “encouraged them to walk and get about again” after an illness. Relatives who completed surveys before the site visit felt they were kept informed and consulted and were satisfied overall with the care their relatives receive. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 12 - 15 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The daily routines and activities provided meet residents’ needs and are flexible. Residents keep in contact with their family and friends. EVIDENCE: The matron organises activities and outings for the residents. These include bingo, arts and crafts, chair aerobics, church services, fetes, shopping and walks. Residents were enjoying a game of bingo during the site visit. A resident spoke of two birthday parties that had been held recently for residents and of how they had enjoyed these. Residents said that their relatives and friends visit them regularly. A number of people came to see residents during the site visit. Relatives said they were welcome to visit at any time and can visit their friend or relative in private if they want to. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 13 Copies of menus were seen. These had been planned ahead and included alternative choices for residents to choose from. The cook said that she was familiar with residents likes and dislikes and if the choice for the day is something she knows they dislike she makes them something she knows they do like. Records of what residents had eaten each day showed they have a variety and choice. Residents said they enjoyed the food and had plenty. One said “have a good caring cook who understands my needs, likes and dislikes”. Some residents had the midday meal in the dining room. Staff brought others theirs in their room. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 16 and 18 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives’ complaints are taken seriously and investigated and they are safeguarded from abuse. EVIDENCE: Information received before the site visit stated that there had been no complaints received by the home since the last inspection. The complaints procedure is on display in the entrance hall. It gives details of how to complain, timescales for investigating any complaint and details of how to contact the Commission. Training records showed that staff had attended training in the protection of vulnerable adults. Staff were clear about what to do if they suspected abuse. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 19 – 21 and 23 - 26 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and comfortable home with private and communal rooms that meet their needs. EVIDENCE: Work on the refurbishment and extension works is well underway. When completed there will be an additional 15 bedrooms, making a total of 39 single rooms. All will have en suite facilities. There will also be 5 bathrooms, a new kitchen, lounge, dining room, hairdressing room and a sluice room. The current laundry will be extended. Work is due to be completed at the beginning of September 2006. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 16 At the time of the site visit one half of the home had been completed and the residents were all living in this area. The other half was blocked off for residents’ safety while the refurbishment and extension works in this part of the home are completed. The new kitchen is now in use and the dining room was also being used as the lounge until the new lounge is completed. There are plans to build a conservatory on the patio area leading from the dining room/lounge and to landscape the gardens at the back. The front of the building has been paved and provides limited car parking. The communal areas of the home have been re-decorated. They were pleasant and airy despite it being a very hot day. The home was clean and hygienic and there were no unpleasant odours. One of the two new shaft lifts is now in operation for residents whose bedrooms are on the upper floors. Residents’ rooms were attractively decorated with matching curtains and bedspreads. They were individual to them and met their needs and tastes. They had their own personal items including photos, pictures, televisions etc. All had en suite facilities. The laundry is in a building in the garden. When extended it will have a sink, industrial washing machines and dryers. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 17 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s recruitment procedure. They are supported by staff who have the skills to meet their needs. EVIDENCE: At the time of the site visit there were 18 residents living in the home. The acting manager was not on duty, but the matron was in charge of the home in their absence. There were also five care staff, a cook and two domestics on duty. This was clearly enough staff to meet the needs of the residents in the home at this time. Relatives who returned surveys to the Commission prior to the site visit felt there were enough staff on duty. The matron confirmed that three care workers are on duty each morning and afternoon and two waking care workers every night. Domestics now work Monday to Saturday to keep the standard of cleanliness of the home the same at weekends as in the week. Currently 10 care staff work in the home. Seven of these have achieved an NVQ in care. The matron confirmed that new staff were being recruited. This is so that staffing levels can be increased as more residents move into the home after approval is received for the increase in numbers from 24 to 39. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 18 Files were seen for three members of staff, two of which had been recruited in recent months. All relevant checks and documentation including CRB and POVA first checks had been obtained and were seen on file. All staff follow an induction course when they first start. Information received prior to the site visit showed that staff had attended training in a number of subjects since the last inspection. These included, risk assessment, infection control, health and safety, dementia, care planning, food hygiene and manual handling. Staff said they have been able to attend the training they need to be confident they can care for residents well and meet their needs. Staff files contained details of the training staff had attended, the dates and certificates. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 19 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, and 35 - 38 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-managed home that is run in their best interests and safeguards their rights. EVIDENCE: The manager who had been appointed when the last inspection took place has now left. A senior carer is acting into this role at present. This person has worked in the home for a number of years. During this time they have developed their skills and knowledge in the management of care and have undertaken the Registered Managers’ Award. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 20 The matron advised that the manager post has been advertised. A competent permanent manager who has the qualifications and experience required must be recruited as soon as possible. An application must then be made to the Commission for their registration as manager. Previous quality assurance surveys have been carried out to get the views of residents and their families about the home. The matron said that she expected these surveys to be resumed once the refurbishment and extension works were complete. Information received before the site visit indicated that the home does not act as appointee for any residents. Small amounts of money are kept for some residents. Records are kept of how much is spent, on what and receipts. These records were not very clearly laid out and it was suggested a more organised method is used so that the information is clearer and easier to follow. The balance on these sheets was checked against the money held for three residents. These tallied. Each resident’s money is kept separately and securely. Supervision records were seen in staff files. These showed that staff are supervised regularly. Staff spoken to said that they receive regular supervision from the acting manager and felt well supported. The new kitchen is now in use. This has been fitted out with new equipment. The fridge and freezers in the kitchen contained milk, bread, fruit, eggs etc., and jars of jams and sauces. There was no record of when these had been opened. Records must be kept to be sure that residents are not given jams or sauces that have been open longer than the length of time specified on the label. There is an additional fridge and freezer in the dry store in the basement of the home. This area also houses the new boilers and was very warm. Although the temperatures of the fridge and freezers in the kitchen are checked and recorded daily to make sure food is kept at the right temperature, this is not being done for the fridge and freezer in the basement. The temperature of all fridges and freezers must be checked and recorded daily. It is particularly required in the basement because the fridge and freezer are next to the boilers. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 21 Both the matron and cook were concerned about the potential risk these omissions posed to residents and assured the inspector that they would deal with them that day. Staff spoken with said that fire alarms are tested and regular fire drills are held. They were clear and confident about what to do if the fire alarm sounded. Training records showed that staff have attended fire and manual handling training and this is kept up to date. Information received prior to and records seen during the site visit showed that all relevant maintenance and checks have been done and are up to date. Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 22 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. 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 13(4) Requirement Comprehensive risk assessments must be carried out that are individual to each resident and identify specific risks for them, action to be taken and the outcome to be achieved. This is part of a requirement made, and carried forward from, the last inspection. A qualified, competent and experienced manager must be recruited. Application for their registration as manager must be made to the Commission. Jars of jams, sauces etc., must be dated when opened to avoid food poisoning. The temperature of all fridges and freezers must be checked and recorded daily to ensure that food is being kept at appropriate temperatures. Timescale for action 02/10/06 2. OP31 9 02/10/06 3. OP38.2 16(2)(g) 03/08/06 Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mandalay Residential Home DS0000056632.V300352.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Kent and Medway Area Office 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 DS0000056632.V300352.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!