Inspection on 21/07/05 for The Mandalay

This inspection was carried out on 21st July 2005.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mandalay 24/01/09

The Mandalay 14/02/07

The Mandalay 27/02/06

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 Susan Hall Announced 21/7/05 at 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Mandalay Address 103-105 Blenheim Road, Deal, Kent. CT14 7HA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01304 365587 Mrs M Sewell Mrs M Sewell Registered Care Home 6 Category(ies) of Young Adults with Learning Disabilities registration, with number of places The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21.09.04 Brief Description of the Service: The Mandalay is situated in a quiet residential area of Deal, within walking distance of a 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, and are available to staff and Service Users on most days. The Home has a relaxed family atmosphere, and is suitable for its registered purpose of caring for younger adults with learning disability. Accommodation is for up to 6 adults, 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 2 allottments situated closely behind this, and they are available for Service Users to help with gardening, if they enjoy this. Mr. and Mrs. Sewell also provide day care on the premises for other Service Users as well as their own. Day care is not currently inspected by CSCI, and so this is not reflected elsewhere in this report. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection commenced at 09.30, and finished at 4.15pm. The Inspector was welcomed by the Manager and the Assistant Manager - (the Manager’s son, Nathan Sewell), - and both were available for most of the inspection. The Inspector had received 4 CSCI comment cards from Service Users. They had gone to a lot of trouble to complete these, and one had included a letter to the Inspector. One Service User had asked the Assistant Manager to help with completing the form. These helped the Inspector to confirm her own findings. Each of these forms contained positive comments, and stated that the Service Users enjoyed living in this Home. The Inspector was able to meet and chat with all 6 of the Service Users. One of these does not have verbal communication, but made it quite clear to the Inspector that he is settled in the Home; two of the others only chatted briefly, but the Inspector had contact with the other 3 quite frequently throughout the day. The Inspector was also able to talk with 2 staff, as well as the Providers and the Assistant Manager. The inspection included a tour of the Home and garden, and viewing of 5 of the 6 bedrooms. One of the Service Users did not want the Inspector to look in his room. The Inspector viewed documents such as care plans, risk assessments, daily records, accident reports, staff files and medication charts. What the service does well: The Home provides a relaxed, friendly and secure environment, where Service Users are able to develop their own abilities within a supportive framework. There is an emphasis on encouraging Service Users with their own choices, and enabling them to decide on their preferred type of lifestyle. Service Users expressed that they had “lots of fun”, and some stated that they were pleased with how well they were achieving new life skills. The staff try to ensure that Service Users are able to have the educational opportunities they want, and to find work experience for them where possible. Two had written comments stating that “the staff look after me well and care for me.” The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The Service Users’ daily reports were well written, but most entries were not signed and dated. There is a recommendation to ensure that staff sign their entries with a clear initial and surname, taking accountability for the items written. Medication charts did not include a record of the numbers of tablets received into the Home, and returns to the Pharmacy were not documented. There is a requirement to amend this practice. The Manager stated that a record of complaints would be stored in the Home, but there was not a complaints record book which could be accessed by any staff, at any time. There is a requirement to implement a complaints record book, and the Manager said that she would discuss this at the next staff meeting. There is also a recommendation to improve the format of the complaints procedure for Service Users, so that it is easier for them to understand. Staff files were neatly put together, and were generally improved, However, the Inspector noted that 2 files did not contain a proof of identity, or a photograph, and there is a requirement to ensure that all information required about staff is kept on file. General risk assessments for the Home were very detailed, but the Inspector thought these should be added to individual Service User plans as well – eg: use of knives, going out of the Home etc. There is a recommendation to include these in Service Users’ files. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 7 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 H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 1-5 The Statement of Purpose and Service Users Guide contain detailed information, enabling prospective Service Users to understand some aspects of how the home functions, prior to visiting it. The admission process helps Service Users to settle into the Home, and know that their needs will be met. EVIDENCE: The Statement of Purpose includes the required information, and is set out in a straightforward format. The Service Users’ Guide had been newly produced as a booklet with pictures, photographs, symbols and large print. As well as being an attractive document, it also contains all the necessary information for new Service Users to understand the ground rules of the Home. This is read through to new Service Users, and discussed at a level they can understand. The Manager said they were also planning to put this into a DVD format. New Service Users are not admitted until an agreed care plan has been set in place with help from the Care Manager and family members. Each plan is drawn up to meet the individual needs of that person, and specialist guidance is sought from other professionals where applicable. Service Users have as many visits as are needed prior to moving into the Home, and this gives them the opportunity to get to know staff, and to check that they will fit in well with other Service Users. Emergency placements may The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 10 be taken from time to time, but as much information as possible is accessed prior to agreeing to this course of action. Any Service User with an emergency placement would be re-assessed within a few days. One of the current Service Users had been admitted as an emergency placement, and a decision had later been made for permanent stay, as he is developing so well, and is happy in the Home. The Manager was able to show how additional help is obtained where needed, as one new Service User is partially sighted, and the management applied to Kent Association for the Blind to ensure that the placement would be suitable. Service Users with communication difficulties have additional assessments, to ensure that staff can communicate effectively with them. Some staff have makaton training, and can communicate well with this method of signing. After initial assessments, there is a 3-month settling in period before a further review to decide if permanent stay is indicated. The Inspector viewed some of the data recorded prior to admissions. This included a “pen picture” of the person concerned, and the reason for possible admission to the Home. Details of personal care needs, and specialist requirements were recorded. These varied from educational and social requirements to managing eating difficulties, or family concerns. All Service Users are given a signed contract, and this includes terms and conditions of residency. Staff go through these carefully with Service Users, to give as much understanding as possible. Conditions include rules about smoking, pets, holidays and additional care such as chiropody. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 6-10 There is a clear care planning system in place, reflecting individual care needs and lifestyles. Service Users are consulted about changes to the Home, and are encouraged to develop their own personal goals. EVIDENCE: Service User plans had been developed on an individual basis, and showed that Service Users’ own unique lifestyles and preferences were taken into consideration. Care plans include details of personal care, family situation, specialist needs and health care. They take into account the Service User’s previous home environment, their social functioning, ability to communicate, mobility and dexterity, community awareness and mental health. The care plans were set out with different sections, in individual folders. Each Service User has a hardback book for support workers to write in daily reports. These are usually completed alongside the Service User, so that the Service User knows what is written about them, and can have input into this process. This also allows some time each day when they know they will have some one to one time with a support worker. These were good records, but were not all signed or dated, although some had been initialled. There is a recommendation The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 12 to ensure that these are properly signed and dated. Care plans are reviewed with Care Managers at 6-monthly reviews, or more frequently if indicated. Service Users are supported as needed in managing their finances. Two Service Users currently managed their own, and four were being given appropriate support. There is sufficient opportunity to take part in making decisions about the Home, through daily informal chats, regular meetings between Service Users and staff, and one to one key worker arrangements. One Service User is also an active member of the Deal Town Council, and is able to voice his opinions clearly in respect of the town. Risk assessments were included in care plans, and included specific assessments for each Service User. One of these was for riding a motorbike, and another for carrying out work experience. The Inspector asked if there were other risk assessments, and was informed that general risk assessments for household risks were stored together in a separate folder. These included risk assessments for use of knives, bathing and showering unattended, use of electrical equipment, and use of glass items. The Inspector recommended that these should be added to individual risk assessments for Service Users, as not all household risks would necessarily be managed the same way for each Service User. Risk assessments should clearly denote any particular steps to avoid risks for different individuals. Service Users’ records were appropriately stored in a locked office, and staff were aware of the importance of maintaining confidentiality. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 11-17 Service Users are given opportunities for individual development, and are enabled to take part in family and community life. Activities and leisure time arrangements are instigated according to their individual preferences. The Home has suitable systems in plac to ensure that Service Users have a healthy and varied diet. EVIDENCE: Care plans included some specific guidelines, so that Service Users are able to learn to modify their behaviour to what is acceptable. These were set out to show what action would be taken if the guidelines were not adhered to, and agreed with individual Service Users. The Home has set up one specific day each week to encourage Service Users in developing individual life skills. These are carried out with the same member of staff overseeing this practice, so that individual developments can be clearly identified. Skills include Service Users making their own bed, tidying their room, putting washing in the machine, and ironing clothes where possible. Service Users also take part in preparing their own lunch on this day. All The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 14 Service Users had shown progress with increasing skills, and some had made significant steps forward. Each Service User has an individual daily programme of activities on a laminated sheet in their room. These are signed as agreed by the Service User. One of these included activities such as making a meal, sewing, drama class, games (specifically a ball game called boccia), other sports, health and beauty session, work experience, literacy, numeracy and pottery. Some of these are carried out at College. Another Service User spent time attending weight watchers, - and had lost a total of four stone. Other skills being developed included making short journeys with only minimal support, going to the library, and listening to tapes/talking books. One Service Users was trying out a first driving lesson on the day of the inspection. Service Users are enabled to attend a church of their choice. Deal is unusual in being able to provide a Special Needs Service through the Baptist Church, and this is appreciated by Service Users in the Home. Work experience is sought for Service Users in line with their abilities and wishes. One helps with a mother and toddler group; another had spent some time working as a handyman in a pub. Service Users join in with Day Care going on in the Home. This is managed by separate staff to those on duty in the Home. This may include gardening on the allotment, cooking, or caring for pets. One Service User has a giant rabbit. Holidays are discussed at length between staff and Service Users, and this year, Service Users had all chosen to go to a holiday complex at a nearby beach. One Service User became quite animated telling the Inspector how much she was looking forward to this. The staff encourage Service Users to maintain and develop links with families and friends, and all Service Users have some family involvement. Menus are discussed together, and Service Users are encouraged to choose healthy options. Most food is home cooked, and some is home grown as well. The Environmental Health Officer had visited in February 2005, and his report confirmed that requirements he had made about the kitchen had been carried out. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 18-20 Personal support is offered in the Home in a way which promotes Service Users privacy and dignity. Good systems are in place to ensure that health care needs are satisfactorily met. Medication administration would be improved by the implementation of some additional safeguards. EVIDENCE: Care plans contained details of support needed with personal hygiene care and making decisions about getting up and going to bed. There is a continued theme of enabling Service Users to manage as much of their own care as possible, and to develop their independence. Records of visits to the GP and clinics were included in the care plans, and the Home is assisted by the Learning Disability Team for specific items such as helping Service Users in managing different behaviours. All Service Users were registered with a GP, but choice of GP is not always an option, due to lack of availability. The Manager was also finding it very difficult to locate any NHS dentists able to take on extra clients. Some dental treatments had been carried out at NHS emergency dental facilities, as there are insufficient dentists available for registration. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 16 The Inspector examined the medication procedures, and noted that no Service Users were self-medicating. The Manager stated that their risk assessments precluded this from being a possibility. The Home had recently changed the dispensing pharmacy, due to breaches of safe guidelines. Medication had been handed over to a Service User on the doorstep on one occasion, and this was recognised as an unsafe practice. A local chemist dispensed medication in boxes and bottles. These were properly labelled, and no out of date medication was seen. External creams were stored separately from internal medication. Medication is stored in a locked cupboard, at a low level. There are no hand washing facilities in this room, but hand washing can be carried out in the adjacent kitchen. The Inspector noted that the storage cupboard is wooden. While there is no specific requirement in the guidelines “ Administration and Control of Medicines in Care Homes” (produced by the Royal Pharmaceutical Society), it is recommended that the Manager reviews this situation, and purchases a metal medicines storage cupboard for better security. The Home had produced their own medication administration records, (MAR charts) and these were well completed. However, there was no record of medication receipted into the Home, or of returns to the Pharmacy. There is a requirement to implement these practices, so that an audit trail can be maintained. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 17 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 standard(s) 22, 23 Service Users know that any complaints will be listend to, and action will be taken to address the situation. Staff are trained in understanding and recognition of abuse, and how to protect Service Users who are vulnerable adults. EVIDENCE: The Home has a satisfactory complaints procedure in place, and Service Users know that they are listened to. There had been no complaints made to CSCI since the last inspection, although the Inspector had been informed of one concern which was being followed up by the Home in regards to a staffing matter. The Manager stated that any correspondence used in following up complaints would be kept on file, and an incident book is maintained by staff. However, there is no specific method of recording complaints – either in book form, or in a file, and the Inspector required that a separate complaints record is maintained. The Manager said that this would be discussed with staff at the next staff meeting, to ensure that all staff understood the importance of documenting complaints, and showing any action taken in response. The Inspector also recommends that the complaints procedure is put into a similar format as the Service User Guide, to enable Service Users to understand it more readily. Staff had been trained in recognition and prevention of adult abuse, and had also attended a course for “management of violence and aggression.” The Home would not expect to need to use restraint procedures, but staff are The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 18 trained in case this is ever needed as a last resort. Staff would expect to be able to manage difficult situations with these Service Users by applying deescalation skills. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 19 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 standard(s) 24-30 The environment is homely and comfortable, and suitable for its registered purpose. Bedrooms and living areas are suitably furnished and decorated. Suitable bathroom and washing facilities are provided and satisfactorily maintained. EVIDENCE: The Providers have put in a considerable amount of work to upgrade the premises over the last 2 years, and this work has been well completed. All bedrooms are for single use, and are decorated according to the preference of each Service User. Bedrooms included personal items and possessions, and comfortable armchairs or sofas. One bedroom has an en-suite toilet and wash basin, and all other rooms are fitted with wash basins. All bedroom doors are fitted with locks, and Service Users choose to use these according to preference. There are 2 bathrooms, and both of these have showers over the baths, enabling Service Users to choose their preference of bath or shower. There are 2 additional toilets on the ground floor. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 20 The ground floor includes a homely kitchen area, which is the hub of the Home. There is an armchair and television at one end of this rooms, as one of the Service Users particularly likes to sit there and watch TV at certain times. There are 2 lounges – one of which is intended for the Providers, but they allow Service Users to use it as well sometimes. One of the lounges has a quiet area at one end, and there is an activities area attached to a separate Service Users’ kitchen, which has comfortable seating. This is a favourite place to sit with friends. The Service Users’ kitchen is used to train Service Users in making their own snacks and drinks. Additional equipment has been provided for one Service User with partial sight, and includes anti-glare cooker lighting and indicators. A utility room is next to this kitchen, and is fitted with 2 washing machines and a tumble dryer. The Providers try to ensure they purchase machines with simple buttons and instructions, which are suitable for Service Users to understand. Service Users have their own individual laundry containers, and usually do their own washing each day. The Home was clean throughout, and there were no offensive smells. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 Staff relate well to Service Users, and show a good understanding of the levels of support needed. Recruitment practices have improved, but need some further attention to ensure that staff files are accurately maintained and up to date. Staff were receiving approprate supervision from the Manager. EVIDENCE: Staffing levels are assessed according to the dependency levels of Service Users, and if they need one to one care. The rota showed that there are usually 4 support staff on duty in the mornings, 3 in the afternoons and 2 at night (1 waking, and 1 sleeping). This may vary depending on where Service Users are going, and what they are doing. A waking night staff was currently needed because of one Service User being restless during the night, and having a tendency to wander in the Home. The rota showed different staff names, but did not clearly identify the hours worked. The Inspector mentioned that including these would be helpful for authorised professionals to understand the staffing hours more clearly. Staff are aware of their different roles and responsibilities, and are allocated to different Service Users as key workers. A staff member is identified on the rota each day to specify who is responsible for cooking lunch and tea, so that this is clearly understood. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 22 Staff files were in much better order than previously, and the Inspector appreciated the work that had been put in to improve these. A new application form had been produced, to include details of previous work, and to show up any gaps in employment. Applicants are required to complete a health statement, and a statement regarding any previous criminal convictions, and 2 written references are obtained. All staff are supplied with job descriptions and contracts, which include terms and conditions of employment. The Inspector examined 5 staff files, and noted that 2 of these did not include a proof of identity or photograph. There is a requirement to ensure that all required data are included on all staff files. The Home has a good skill mix of staff, with some highly trained staff, and some new staff. There is already above 50 of staff trained to NVQ 2 or above, and new staff were due to commence this training in September 2005. Service Users take part in interviewing prospective employees. No agency staff are used, as this would be unhelpful for Service Users. General staff supervision is carried out on a day to day basis at handovers. One to one staff supervision sessions are carried out by the Manager, and this time is used to assess strengths and weaknesses, and areas of training needed. Yearly appraisals were being commenced. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37-39, and 41 42 The Manager provides clear leadership in the Home, promoting an open and positive atmosphere. Service Users are consulted about their views, and these are taken into account. Record keeping in the Home has improved. Staff are appropriately trained in mandatory subjects to ensure that Service Users safety and welfare are protected. EVIDENCE: The Manager has completed training in NVQ 4 and the Registered Managers’ Award (RMA). She has many years of experience of caring for people with learning disability, and is very motivated to ensure that these Service Users are given a good quality of life. She is continuing to study for a BA in Health and Social Care. Staff and Service Users are invited to share their views about how the Home is The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 24 running. This is carried out informally most of the time, although meetings are held for discussions. The Assistant Manager was in the process of drawing up a questionnaire system, whereby different questions could be asked at different times in the year. (eg – 2 to 3 questions at a time, so it is not too difficult for Service Users.) Feedback is obtained on a daily basis in relation to activities, living skills, and friendships. The Manager stated that policies and procedures had been reviewed and updated as applicable, but the Inspector did not view these at this visit. Service Users know that their records are kept locked up, but that they can ask to see their own records at any time. Staff training records confirmed training in moving and handling, fire awareness, first aid, and basic food hygiene. An infection control course was being implemented. These training subjects were ongoing, to ensure staff stay up to date in the relevant subjects. The Manager had carried out intensive fire drills with staff and Service Users together, until she was sure that they all understood the procedures, where to go, and what to do. Random fire drills are carried out to maintain this understanding. The Inspector viewed documentation for gas, electricity, and insurance, and these were up to date. Accident records had been satisfactorily completed. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 4 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Mandalay Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 3 3 x H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 (2) Requirement To maintain records for numbers of tablets received into the Home, and returns of any unused medication to the Pharmacy. To implement a separate complaints record. To ensure that all staff files contain all the required data as outlined in Schedule 2 of the Care Homes Regulations. Timescale for action 21.08.05 2. 3. YA22 YA34 22 (8) 19 and Schedule 2 21.08.05 30.09.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA6 YA9 YA20 YA22 Good Practice Recommendations To ensure daily records are properly signed and dated. To include general risk assessments in individual Service Users plans. To consider purchasing a metal cupboard for storage of medication. To consider putting the complaints procedure into a more suitable format for Service Users to understand. The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 11th Floor International House Dover Place Kent TN24 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 The Mandalay H56-H05 S23113 The Mandalay V229030 210705 Stage 4.doc Version 1.40 Page 28 - 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. 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