Inspection on 14/02/07 for The Mandalay

This inspection was carried out on 14th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

The Mandalay 24/01/09

The Mandalay 27/02/06

The Mandalay 21/07/05

The Mandalay 21/09/04

The Mandalay 13/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 The Mandalay 103-105 Blenheim Road Deal Kent CT14 7HA Lead Inspector Christine Lawrence Key Unannounced Inspection 14th February 2007 11:00 The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 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 The Mandalay DS0000023113.V307174.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 Adults 18-65. 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. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mandalay Address 103-105 Blenheim Road Deal Kent CT14 7HA 01304 365587 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) Marianne Sewell Marianne Sewell Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27 February 2006 Brief Description of the Service: The Mandalay is situated in a quiet residential area of Deal, within walking distance of the town centre, a local leisure centre, and the sea. The premises are made up of two adjoining Victorian style terraced houses, which are linked internally to provide one unit. The providers, Mr. and Mrs. Sewell, live on the premises. Accommodation is for up to six people, with bedrooms and bathrooms on the first and second floors. Communal living facilities are on the ground floor. There is a rear garden which includes a small patio area, a lawn and a fishpond. There are two allotments situated beyond the garden. Information about the home, including the latest report from the Commission for Social Care Inspection (CSCI). Information included in the pre-inspection questionnaire provided by the manager prior to the visit to the home, confirmed the fees as between £501.57 and £764.56 per week. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and started at 11.00 and finished at 17.00. The inspector looked at various records in the home and also used information sent to the commission by the owners before the visit. Information from the previous inspection was also referred to. The inspector spoke with several of the residents and was invited to see some bedrooms. A tour of the parts of the rest of the building was undertaken. The inspector made observations of staff interacting with and supporting residents. Comment cards were completed by various health and social care professionals and the information they provided is also used for this report. What the service does well: 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ individual aspirations and needs will be assessed. EVIDENCE: Three individual records were looked at for this inspection. It is clear that new residents will only be admitted after a detailed assessment process which includes getting information from the placing authority’s representative. The assessment information is used to compile a care plan. The format being used in the home is based on person centred planning and focuses on an individual’s wishes as well as their needs. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their changing needs will be noted in their individual plans and that they will be supported to make decisions and take risks to enable as independent lifestyle as possible. EVIDENCE: Three care plans were viewed for this inspection. They are written from a person-centred viewpoint and Marianne Sewell and Nathan Sewell made it clear that they are always looking at ways to improve and personalise these formats and to fully reflect that residents are involved. Information from placing authorities was seen and the home uses this to inform their care planning. Risk assessments are in place, both for individuals and for the environment. The risk assessments reflect a commitment to enabling as much independence as possible. Residents are involved in drawing up any plan and some of them shared with the inspector their weekly plans. There is a key worker system in place and residents gave examples of how that helped and supported them. The care plans are regularly reviewed and this includes residents, their representatives if appropriate and health and social care The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 9 professionals. The residents who spoke to the inspector were confident and clear about their rights and responsibilities in the home. A residents’ guide has ‘Dos and Don’ts’ relating to how everybody should behave in the shared living situation. An example was noted of how residents use this document. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities and involvement in the local community, as well as support for personal relationships will be provided for residents. They will benefit from being offered a healthy diet and a sociable setting for mealtimes EVIDENCE: Residents living at The Mandalay take part in various activities, both educational and recreational. They use local facilities such as colleges, The Mandalay Day Service, DealAbility (drama), local libraries, swimming, bowling, boccia, pubs and clubs, and many more too numerous to list. Facilities within the home include responsibilities for housekeeping (both individual and communal), gardening, computers, cooking, arts and crafts, and special evenings such as DVDs with popcorn in the ‘interval’ and disco/buffet nights. Residents also enjoy television and playing music. Examples were noted of the home supporting residents in their relationships with family and friends. Two residents vote in person on a regular basis and The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 11 one other does occasionally. As noted in the previous standard residents are very much encouraged to be as independent as possible and to make choices about their routines. This was reflected in the written information and confirmed by what residents said. The manager confirmed that staff knock before entering a resident’s room and mail is passed to residents, with any necessary staff support for reading it. The menu provided for this inspection had variety and contained meals that were nutritional. Special diets can be catered for. Mealtimes are sociable although they are also flexible to meet the needs and wished of residents. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 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 policies and procedures regarding medication and their physical and emotional needs will be responded to. EVIDENCE: Residents seen during this inspection were individual in their appearance and the inspector was informed that individuals make choices about their clothes and hairstyles. The residents spoken with explained how this happened. Residents’ needs with regard to the level of support they require for personal care varies according to their abilities for instance one person might need lots of help and another might only need encouragement. Information about routines, preferences and likes and dislikes is provided within the individual plan. Some residents are also keen to speak up for themselves and this is clearly encouraged. There are male and female staff within the home. The records seen indicate that residents health care needs are identified and responded to with attention from dentists, opticians, general practitioner, community nurses, dietician etc. Health action plans are in place and as with the person centred care plans, Marianne Sewell and Nathan Sewell confirmed that they are always looking to ensure that the format is appropriate and personal for individuals. Medication storage has been improved and the The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 13 records seen were properly completed. There are appropriate policies and procedures in place. Staff who are responsible for administering medication have undertaken a 16 day training course (one day a week for 16 weeks) at a local college. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and their views are listened to and acted on. EVIDENCE: The residents spoken to during this inspection were clear about who they should speak to if they were unhappy about anything. Some examples noted showed that the home listens to people and sorts things out before they become a problem. There are formal residents’ meetings but there are also lots of opportunities to chat with key workers and all staff whenever a resident needs to. There is a clear procedure for making complaints and there is an improved format for recording any complaints. There are policies and procedures in place regarding adult protection, whistle blowing, bullying, equal opportunities and management of residents’ money. These policies were all reviewed in November 2006. Staff have received training regarding the protection of vulnerable adults and new staff are undergoing ‘common induction standards’ training in keeping with the recommendations of Skills for Care. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, comfortable and safe for the residents. EVIDENCE: The house is in keeping with the local community and has the style and ambience of a large family home which is consistent with the purpose of The Mandalay. Mr and Mrs Sewell also live on the premises. The house is satisfactorily decorated and furnished and provides different communal areas. The laundry facilities are adequate and there are policies and procedures relating to infection control and hazardous substances (COSHH Regulations). The home was fresh and clean throughout. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sound recruitment procedures and training provided to staff will have a beneficial impact on residents. EVIDENCE: There is a good training programme provided for staff and those seen were observed to be competent and confident. The manager provides induction training within the home in keeping with the common induction standards from Skills for Care. One member of staff is currently undertaking a national vocational qualification, level 2 and three members of staff are doing level 3. There is a balance of experienced and newer staff who can meet the variety of care needs that residents have. The records seen reflect a robust recruitment procedure which includes application forms, references, terms and conditions of employment and criminal record bureau checks. The policies and procedures which the owners have in place cover relevant aspects of recruitment. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and their health and safety is promoted and protected. EVIDENCE: Marianne Sewell is the owner and she has day-to-day responsibility for the home. She has appropriate level 4 NVQs and is also undertaking further qualifications through the Open University. She clearly keeps up to date with current good practice. She works closely with her son, Nathan Sewell who is the assistant manager to ensure that care plans are followed and staff supervision and training is carried out. As previously noted there are regular residents meetings, one to one time with key workers and lots of informal opportunities for residents to express their opinions. Residents spoken to told the inspector that they thought what they said was listened to. There are formal procedures for ascertaining the opinions The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 18 of residents and their representatives and Nathan Sewell is looking at ways for summarising any information received in order to share it with people. The in house reviews also form an important part of the self-monitoring process, involving various people who are concerned with the residents’ well-being and personal development. There are risk assessments for both individuals and the house environment and there are various policies and procedures in place relating to health and safety. The common induction standards cover relevant health and safety training that an individual member of staff might need. The service and maintenance contracts are appropriate. The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 20 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. Standard Regulation Requirement Timescale for action 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 The Mandalay DS0000023113.V307174.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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. 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