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Inspection on 28/04/08 for Mandalay Residential Home

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

This inspection was carried out on 28th April 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What has improved since the last inspection?

A relative commented: `I have seen the improvement over the last few months in the standard of care at Mandalay`. The Statement of Purpose has been updated. Although further development of the care plans are required, care plans are now fully completed for all service users. Mandatory training is ongoing; medication training and adult protection training have been completed for all staff. The manager has audited all staff files and implemented a more robust recruitment procedure.

What the care home could do better:

When asked what the home could improve on one service user commented: `nothing really`. Relatives` comments: `I think the dining room floor sometimes could do with being washed more I thought it was dirty the other weekend`. `I would like to see name badges on staff as it is polite to refer to people by name`. `I would like to see some fundraising activities so a conservatory could be added as I do feel another room is needed to give the residents a change of scene`. The Manager said more domestic staff will be recruited for the weekend and the provider has plans to provide a conservatory this year. Comments with regard to the dining room floor have been addressed in this report.There are seven requirements and two recommendations made in this report. Care plans and risk assessments require further detail to ensure service users needs are met and to reduce the risk of harm to service users and staff when carrying out moving and handling procedures. Additional ancillary staff is required at weekends to ensure all areas of the home are clean. All service users bedrooms doors should be lockable to ensure a person`s right to privacy is upheld. The home needs to consult with Environmental Health with regard to the low banisters in the home to ensure the safety of the service users. The home needs to review the laundry systems to reduce the risk of infection. The home must confirm in writing that they have consulted with the fire and rescue team with regard to the use of gates situated in front of two fire doors. Fire drills also need to be recorded. The home needs to implement a Quality Assurance Programme, and the registered provider or representative must carry out monthly unannounced visits to the home and provide a written report. It is also recommended that the medication storage be reviewed in line with the planned improvements to provide a sink and cold storage facilities. To also consider the space required for medication storage when the home is fully occupied. The home does not currently provide private facilities for service users to make telephone calls.

CARE HOMES FOR OLDER PEOPLE Mandalay Residential Home 10 Julian Road Folkestone Kent CT19 5HB Lead Inspector Mrs Penny McMullan Unannounced Inspection 28th April 2008 09:15 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.V361200.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.V361200.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 F/P 01303 258095 mandalayresidential@hotmail.co.uk Stargate Partnership Ltd Post Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Mandalay Residential Home DS0000056632.V361200.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 5th November 2007 Date of last inspection Brief Description of the Service: Mandalay is registered to provide residential care to 40 older people. The Registered Providers have applied to the Commission for a variation of the category of registration to include 6 places for individuals requiring nursing care. The home has recently been extended and the whole of the premises has been refurbished and redecorated. All bedrooms are single and have en-suite facilities. Communal space consists of a dining room and lounge and there are plans to build a conservatory in the future. Accommodation is over 3 floors and there are 2 shaft lifts. 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 £320.81 and £385.00. Hairdressing, chiropody, transport, papers, toiletries and holidays are at an additional charge. Mandalay Residential Home DS0000056632.V361200.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 1 star. This means that the people who use the service experience adequate quality outcomes. This key inspection was carried out over a period of time and concluded with an unannounced visit to the home between 9.15am and 6.15pm. Residents and staff were spoken to. Observations included interactions between residents and staff. Surveys were sent to the home to distribute to residents, relatives and professionals. Feedback from the people who use the service and relatives is positive. No professional surveys were received back. Various records were viewed during the inspection and a partial tour of the home undertaken, including the communal areas, some bedrooms, bathrooms, and laundry facilities. The proposed Registered Manager is aware of what needs to be developed in the home and is working with social services to achieve the improvements in line with the action plan provided as a result of the adult protections in the home. There have been improvements since the last inspection and the Manager demonstrated her commitment to making the changes to meet the required standards. The AQAA was received on time, however this did not contain sufficient information. It is acknowledged that the Manager was new in post at the time of completion, however it is the Registered Provider’s responsibility to ensure that the assessment is completed appropriately. Improvements in the information provided are required when the next annual assessment is requested. What the service does well: The people who use the service comment: ‘Day staff are good’. ‘The staff are responsive even at night and there are always enough staff on duty’. ‘I am very happy with the home, they help me maintain my independence, I am very happy here’. ‘The home is fine,there are no problems’. ‘I like the dining room it is nice and bright’. ‘The carers are helpful to me’. ‘Staff are good – always enough on duty’. ‘Staff are very good when you are not feeling well’. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 6 Staff comments. ‘I am happy with the way the home is run and I am aware of policies and procedures’. ‘The staff are now working more as a team’. ‘The home tries to promote a friendly home life to meet their needs and family wishes’. When asked if staff listen and action what service users say one person who uses the services said ‘During the day but not at night’. The manager says that the staff have now changed on night duty and the home is currently recruiting to a vacancy. There have been no recorded concerns or complaints with regard to the night staff. Relatives’ comments: ‘There is a clear system of team leaders, deputy and home manager and I have always found everyone approachable, friendly, very supportive and professional’. ‘When my relative was ill recently she had care of the most highest calibre possible plus I received support and care from every member of staff’. What has improved since the last inspection? What they could do better: When asked what the home could improve on one service user commented: ‘nothing really’. Relatives’ comments: ‘I think the dining room floor sometimes could do with being washed more I thought it was dirty the other weekend’. ‘I would like to see name badges on staff as it is polite to refer to people by name’. ‘I would like to see some fundraising activities so a conservatory could be added as I do feel another room is needed to give the residents a change of scene’. The Manager said more domestic staff will be recruited for the weekend and the provider has plans to provide a conservatory this year. Comments with regard to the dining room floor have been addressed in this report. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 7 There are seven requirements and two recommendations made in this report. Care plans and risk assessments require further detail to ensure service users needs are met and to reduce the risk of harm to service users and staff when carrying out moving and handling procedures. Additional ancillary staff is required at weekends to ensure all areas of the home are clean. All service users bedrooms doors should be lockable to ensure a person’s right to privacy is upheld. The home needs to consult with Environmental Health with regard to the low banisters in the home to ensure the safety of the service users. The home needs to review the laundry systems to reduce the risk of infection. The home must confirm in writing that they have consulted with the fire and rescue team with regard to the use of gates situated in front of two fire doors. Fire drills also need to be recorded. The home needs to implement a Quality Assurance Programme, and the registered provider or representative must carry out monthly unannounced visits to the home and provide a written report. It is also recommended that the medication storage be reviewed in line with the planned improvements to provide a sink and cold storage facilities. To also consider the space required for medication storage when the home is fully occupied. The home does not currently provide private facilities for service users to make telephone calls. 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. The summary of this inspection report can be made available in other formats on request. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 8 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.V361200.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents have the information they need before making a decision to move into the home. EVIDENCE: The home has revised the Statement of Purpose to reflect the current management structure and all service users have been issued with a contract of residency. The proposed manager completes a pre assessment form for individual prospective service users. This is completed in conjunction with the care plan from the placing authority, a joint assessment or hospital notes. This information forms part of the care plan. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 10 A postal survey from a service user indicates that they were not given sufficient information before moving into the home. A relative comments: ‘Yes we did receive enough information before my relative came to live in the home. We came to an open day; my son and family also came. We also made further visits.’ The home has the relevant documentation in place for all service users to be given on admission to the home. Another relative visiting the home at the time of the inspection confirmed that they were provided with information before their relative came to live at the home. Standard 6 is not applicable to this home. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements continue in care planning, however there is insufficient detail in parts of the plan to ensure individuals’ needs are fully met and safeguarded from risk. Medication practice is safe and health needs are well supported. Improvements are required to protect the privacy of people living in the home. EVIDENCE: The care plans have improved since the last inspection, however there are still areas that need to be addressed. In some cases there is insufficient information in the care plan to provide staff with guidelines and a safe practice of work, particularly the moving and handling assessments. The current risk assessments in place are not consistently completed and show an overall score Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 12 to indicate the level of risk. The information does not record how to minimise the risk or provide clear guidelines to staff of the manoeuvres to be completed for individuals. No individual preferences or equipment is documented. The plans need to be more person centred to ensure individual care needs are fully met. There are instances where service users who are frail or confused have not had information included in their plan of risk and how they will be monitored. The use of bed rails needs to be reviewed and if required agreed and recorded in line with health and safety and the home’s restraint procedures. Staff demonstrated their knowledge and understanding of the manoeuvres when providing moving and handling but this is not reflected in the paperwork. When moving and handling the lack of information in the risk assessments puts services users and staff at risk of harm. A requirement will be made in this report to address this issue. There are areas in some of the care plans that identify what individuals can achieve and daily notes are completed in a satisfactory manner. The care plans have been reviewed and signed by the resident/representative. Health care needs are monitored in the care plan, including nutrition and continence. All health appointments and visits are recorded. The people who use the service confirm their own doctor visits and other health professionals visit when required. The home has the necessary equipment for the relief of pressure sores and exercise sessions are also provided on a weekly basis. A relative commented: ‘My relative has received good medical care. I know the doctor will be called if necessary and I know the District Nurse would be asked to see her if necessary’. The medication storage is satisfactory and has not changed since the previous inspection. The last inspection reports that further improvements are planned to install a sink and provide a fridge, however no improvements have been made. The home needs to review their medication storage to improve the space and facilities provided. When the home is fully occupied the area where medication is stored may need to be reviewed to ensure there is enough space for safe storage. The home uses the monitored dosage system to administer medication. All staff administering the medication have been appropriately trained and the records are audited by the Team Leader on a weekly basis. Hand written entries are countersigned and records are in good order. A recommendation will be made in this report to review medication storage facilities. The home has not made any improvements to ensure that service users have privacy when using the pay phone; therefore the recommendation from the previous report will be brought forward. Some service users say they have their own mobile telephone and one service user was observed using the Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 13 home’s portable telephone handset. The bedroom doors do not contain locking facilities and this does not respect people’s right to privacy. (Further comments made in Standard 24) The Manager says that one service user has requested a lock and this is being provided. A requirement will be made in this report to address this issue. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is providing a programme of activities for service users that take account of their preferences. Visitors are welcomed in the home and arrangements are in place for the people who use the service to be supported to make choices in their lives. The meals in this home are good, offering both choice and variety. EVIDENCE: Although service users confirm that activities take place, there is still no formal system. A formal programme of events needs to be recorded and displayed so the people who use the service can see what activities are available. The people who use the service did say they have bingo sessions, exercise classes; a singer who visits the home on a monthly basis and someone from the church also comes. At the recent residents meeting the Manager discussed activities and is working with the service users to enable them to be more involved in the planning of the activity programme. Social activities are recorded in the Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 15 care plan. Although there is no formal activity programme in place a requirement will not be carried forward as service users confirm activities are taking place and the Manager is making progress to address this issue. Feedback from the relatives’ postal survey indicates that activities take place on occasions, comments are as follows: ‘There are parties at Christmas and Easter and I have found all the family have been very welcome.’ ‘There are ‘sing songs’ once a month held by the local church. I have always felt very comfortable attending. I don’t have experience of any other activities but have seem them advertised’. ‘There are lots of activities but I never take part. I prefer to stay in my room’ The people who use the service are supported to make individual choices, which are recorded in the care plan. Service users spoken to indicate they are able to get up and go to bed when they wish, some are able to arrange going out with relatives and one service user confirmed she goes out by taxi to her own church. A service user commented: ‘I choose what I want to wear every day as I like to co-ordinate my clothes. The staff are very helpful’. The home has appointed a new cook and all service users spoken to say the food is good with a choice of meals. New menus are being implemented and all meals and cakes cooked are homemade. The kitchen has been deep cleaned and there are cleaning schedules in place. Records seen were up to date and in good order. The home is going to implement the Good Food, Better Business programme. The meal-time was relaxed with the majority of service users choosing to eat in the dinning room. Service users confirm that fruit is available and there is always plenty to eat. There were mixed comments with regard to the meals from the postal survey. One service user said that they sometimes like the meals whilst another says they usually like the meals. Feedback from the services users spoken to at the time of the inspection indicates the food is of a good standard and all said how much they enjoyed the homemade cooking. Another service users comments: ‘The meals are excellent. Fresh produce is always used’. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 16 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. 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. The people who use the service are confident complaints will be listened to and dealt with appropriately. The home is improving the arrangements in place to ensure service users are protected from abuse. EVIDENCE: The home has a complaints procedure on display in the home and there have been no complaints since the last inspection. There are several compliment letters on the notice board and a compliment letter was forwarded to the Commission by a relative. The relative comments: ‘’My relative’s quality of life is as good as it can get, given her disabilities; thanks to everyone at Mandalay’. Other comments from this letter will be used throughout the report. The people who use the service say they have no complaints but would speak to a member of staff if they had any concerns. A service user commented ‘I tell my daughter if I need anything but so far I have been very happy’. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 17 There have been three adult protection alerts and the Manager is responding to the action plan provided by Social Services to improve the service. She is aware of the shortfalls in the home and is working hard to comply with the standards and regulations. The proposed registered manager is a trainer for Adult Protection and all staff have received training. Staff spoken to have demonstrated their awareness of adult protection and procedures. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable well maintained home, however improvements are required to ensure the communal areas are clean. There are shortfalls in the laundry system, which leaves the home at risk of infection. EVIDENCE: The home has been extensively refurbished and is well maintained with furnishings and fittings to a high standard. There is a garden at the rear of the home where a conservatory will be added in the near future. The Manager confirms that the home complies with the requirements of the fire department and environmental health, however there are still two areas of the home Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 19 where stair gates are obstructing fire escapes. The Manager says that she has raised this issue with the Registered Provider and she been advised by the company’s representative that this is acceptable. This was a requirement from the last inspection and although the home feels that they have taken advice with regard to this issue, this was not clearly documented and they could not confirm that the representative has consulted with the fire and rescue authority. The home must therefore confirm in writing that the organisation has consulted with the fire and rescue authority regarding the evacuation of service users in the event of a fire and appropriate risk assessments are in place. A requirement will be made in this report. The Registered Provider or Company representative has not completed a monthly Regulation 26 visit. A requirement will be made in this report. The last visit recorded on file is 26 October 2007. The unfixed toilet frames have now been fixed to the wall and it was observed that the COSHH items were safely stored. The permanent storage of linen has been reviewed and trolleys have been purchased and placed in a bathroom in each wing to provide storage space for the clean laundry. The home has provided an overhead bedside light with a pull string for one service user who was unable to have a bedside table due to the layout and shape of the room. The home has the necessary equipment to maximise service users independence and grab rails and other aids are in place. The call system is available in all areas of the home and it was observed that two service users in their rooms had their call bells placed near them for easy access to call the staff. Rooms seen are well decorated and furnished with individual service users possessions. At the time of the inspection none of the bedroom doors had locks so therefore no service users have been risked assessed with regard to having their own keys. The people who use the service are therefore unable to lock their doors to maintain their privacy if they wish to do so. See previous comments Standard 10. A requirement will be made in this report to address this issue. The bedrooms and en suite facilities are very clean and feedback from the people who use the service and relatives confirm the rooms are cleaned on a regular basis. One service user comments: ‘My room is cleaned daily. The bathroom is always clean and my bed linen is changed regularly’. The laundry facilities are situated in a separate building outside of the main home and at the time of the inspection there was only one entrance. This is through the dining room. Whilst in the dining room it was observed that soiled linen was taken through the dining room on two occasions and on a third occasion whilst the service users were having lunch clean linen was brought Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 20 into the home. The soiled linen was not in the appropriate bags or trolleys to reduce the risk of infection. At the last service user meeting the minutes reflect that one service user has suggested the owner builds a covered walkway for the carers to use. There is evidence in the staff meeting minutes that the Manager has discussed the importance of infection control procedures. This system needs to be reviewed in line with infection control guidelines. The home needs to consult the Infection Control Team for professional advice as to how to manage this situation. A requirement has been in this report. On arrival in the home at the lounge and dining room floor had not been cleaned. In the lounge there were tissues by chairs on the floor and it was apparent the carpet needed a vacuum. The dining room floor also needed to be cleaned. Both areas were cleaned later in the morning. There is only one domestic on duty on Sunday, which reflects on the amount of cleaning that can be done. Three chairs in the dining room had food squashed on the cushions and a soiled tablecloth was on one chair, this was not visible until the chair had been pulled away from the table. The home needs to ensure that all communal areas are cleaned appropriately and there is enough domestic staff on duty. A requirement will be made in this report. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient well trained staff on duty who have been appropriately trained to meet the needs of the people who use the service, however additional weekend ancillary staff are required to ensure that all areas of the home are clean. Arrangements are in place to ensure that residents are protected by the homes recruitment policies. EVIDENCE: The staff rota shows six carers on duty in the morning, additional to the carers there is usually a Deputy Manager or Manager on duty, five carers in the afternoons and four at night. The accommodation ranges over three buildings and deployment of staff is allocated each day to ensure that all areas of the home is covered and they have the opportunity of working with all levels of dependency of service users. There are currently four service users who require two carers to assist with their care needs. There is a clear staff structure in place and the general opinion of the staff is that there is usually enough staff on duty. One member of staff comments that sometimes at weekends due to sickness there can be some staff shortages. The home endeavours to cover absent staff and in the past have used agency staff. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 22 Currently there is only one domestic staff member on duty on Sunday, which results in minimal cleaning duties being carried out. The staffing levels need to be reviewed to address this shortfall as previously mentioned (Standard 26) and improvements in the cleaning of the communal areas needs to be addressed. A requirement has been made in this report to ensure there is enough ancillary staff on duty especially at weekends. As a result of this issue the Manager has now advertised for an additional weekend domestic post. A relative commented: ‘I find all the staff are very approachable and I am quite happy to speak to whoever is on duty if I need help’. Service user comment: ‘The staff are always available however I never use the call system unless I really have to’. Over 75 of the care staff have achieved NVQ II and a new member of staff is scheduled to start the course in the near future. The Manager has audited the staff files to ensure that all documentation is in place. Staff files seen are in good order and contained the relevant documents to ensure that staff have been appropriately vetted. The manager has taken steps to address some missing documents. A new application form has been implemented. Some of the missing documents refer to staff that have been employed over two years ago and these shortfalls have been highlighted and recorded. The Manager is in the process of implementing additional information in the organisations Recruitment Procedures with regard to Criminal Records Policy and will be discussing the amendments at the next staff meeting. The home has a training programme in place to ensure mandatory training and relevant updates are provided. There is a shortfall in all staff receiving first aid training and the Manager says that this will be booked for this year. The induction training has been amended to ensure staff are able to demonstrate they are competent to do their job. Staff confirm that training takes place and additional courses in dementia and nutrition have also been booked for this year. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has an awareness of service shortfalls and is taking action to address these. Improvements are required to ensure that the service user’s views are influential in the development of the service. Arrangements are in place to ensure the people who use the service financial interests are protected. Further improvements are required to protect the health and safety of the people who use the service and the staff. EVIDENCE: Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 24 The Manager has been in post since August last year and is working to improve the home in line with the standards and the action plan, which was a result of the recent adult protections. She has applied to the Commission to be the Registered Manager of the home. She is an experienced qualified Manager. Feedback from staff indicates that they feel supported by the management team. The Manager is in the process of implementing a quality assurance programme. A service user meeting has taken place and further meetings are planned to include relatives. Questionnaires for residents, relatives, staff and care managers are in place but they have not been forwarded or completed. The home needs to complete the quality assurance programme to ensure that the people who use the service have a say in the running of the home. A requirement will be made in this report. The home manager and deputy manager look after personal allowance monies and ensure that the relevant records are in place. Records were viewed and were found to be accurate and in good order. Receipts are in place and some service users are able sign for any monies issued. Mandatory training is in place and appropriate safety checks have been carried out. At the time of the inspection the fire extinguishers were being serviced. Environmental risk assessments are in place and risk assessments have been implemented for each service user who is able to use the stairs. There is an issue over the height of one banister on the stairs near the entrance of the home. The Manager needs to ensure that Environmental Health is requested to visit the home to assess the safety of the banister. The Manager has telephoned and requested a visit. Improvements are also required with regard to infection control systems in the home, as previously mentioned in Standard 26. There is also an issue with regard to the gates restricting fire doors, this has been previously mentioned in Standard 19 and will need to be resolved by the home. The home needs to confirm that they have consulted with the fire and rescue authority to ensure safe practice and appropriate risk assessments are in place. The fire book was in good order with evidence of tests, however the fire drills were not appropriately recorded there was evidence that a fire drill had taken place but no formal records to confirm this. A requirement will be made in this report. The Manager carries out six monthly health and safety checks and water temperatures are recoded. Records show a considerable amount of fluctuation in the water temperatures. The home needs to record what action is taken to Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 25 address this issue. The Manager says the plumbers are looking into the reasons why this is happening. The accident book was accurately completed and tracked through to the individual service user plan where appropriate action had been taken. The home has an emergency evacuation plan in place. Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 26 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 2 x x 3 x 2 x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 15 (1)(2) Requirement Care plans need to include further details of how to meet service users needs and risk assessments need to provide staff with clear guidelines of how to minimise the risk and provide a safe practice of work. To consult with the Environmental Health Office with regard to the safety of the banister situated on the front stairs by the entrance of the home To home must confirm that they have consulted with the local fire and rescue authority with regard to the use of the gates, which restrict two fire doors. To review the laundry systems in the home to reduce the risk of infection To provide locks on bedrooms doors to uphold the privacy of individual service users The home needs to ensure that DS0000056632.V361200.R01.S.doc Timescale for action 31/07/08 2. OP19 13 (4) (a) (b)(c) 23 (4)(5) 31/05/08 3. OP24 12 (4)(a) 13 (4)(a)(c), 23 12 (1)(a) 31/07/08 4 OP26 31/05/08 Page 28 Mandalay Residential Home Version 5.2 5. 6. OP33 OP33 24 (1) (a)(b) (2) (3) 26 (1) 2(a-c) all communal areas are cleaned appropriately and there is enough domestic staff on duty. To implement a Quality Assurance Programme The registered provider or representative to carry out monthly unannounced visits to the home and provide a written report. To ensure that fire drills are recorded. 31/07/08 31/05/08 7. OP38 23 (4)(e) 31/05/08 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. Refer to Standard OP9 Good Practice Recommendations To review the medication storage in line with the planned improvements to provide a sink and cold storage facilities. To also consider the space required for medication storage when the home is full. It is recommended that private facilities be made available for residents to make telephone calls. This recommendation has been brought forward from the previous inspection. 2. OP10 Mandalay Residential Home DS0000056632.V361200.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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