Care Home: Mandalay

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What the care home does well People live in a home which is decorated, furnished and maintained to a high standard. A good range of activities both `in house` and within the local community are provided so as to ensure that people have their social care needs met. People who live at the home have a support plan which provides details of their care needs and how these are to be met by staff working at the home. People feel confident to raise concerns and/or issues and feel that they are listened to. What the care home could do better: Ensure that information recorded within the pre admission assessment is informative and detailed and there is clear evidence so as to determine the needs of the individual person can be met. In addition evidence of transitional visits and the progress of such visits must be recorded. Incidents which are notifiable under Regulation 37 Notifications must be forwarded to us in a timely manner. Information should include details of the incident, people involved, actions taken and outcome.The registered provider must ensure there is a regular system in place to seek the views of the people who live at the home, their representatives, staff and other stakeholders about the quality of the service provided at Mandalay. The results of the surveys should be collated and an action plan arranged. Regultion 26 visits must be conducted each month by a representative of the organisation and a detailed report compiled. Ensure that all support staff working at the home receive regular formal supervision. A record should be maintained of the supervision detailing the areas discussed, actions to be undertaken and the details of who is responsible for ensuring they are actioned. Random inspection report Care homes for adults (18-65 years) Name: Address: Mandalay 13 Bridge Street Witham Essex CM8 1BU two star good service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Michelle Love Date: 1 5 0 6 2 0 1 0 Information about the care home Name of care home: Address: Mandalay 13 Bridge Street Witham Essex CM8 1BU 01376520280 01376509021 Telephone number: Fax number: Email address: Provider web address: Voyagecare.com Name of registered provider(s): Name of registered manager (if applicable) Mrs Mary Grant McIlvaney Type of registration: Number of places registered: Conditions of registration: Category(ies) : Voyage Ltd care home 6 Number of places (if applicable): Under 65 Over 65 0 learning disability Conditions of registration: 6 The maximum number of service users who can be accommodated is: 6 The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Date of last inspection Brief description of the care home Care Homes for Adults (18-65 years) Page 2 of 10 What we found: This was an unannounced random inspection. The visit took place over one day by one inspector and lasted a total of 4.5 hours. The purpose of the site visit was to monitor compliance to the Outcome Groups relating to Personal Care and Healthcare, Concerns, Complaints and Protection and Conduct and Management of the Home. The home is registered for 6 people who have a learning disability and at the time of the site visit there was one person living at Mandalay. A new manager has been employed at Mandalay since 18th March 2010. From discussions with them it was evident they have the skills and experience to manage the care home and have previous knowledge of the specific client group that is catered for at Mandalay. The manager has not yet submitted an application to the Care Quality Commission to be formally registered but stated that she is waiting for her Criminal Record Bureau check to be returned. From discussion with the manager she advised that her ethos for the service is to ensure that young people who come to live at Mandalay are given the opportunity to live an ordinary and meaningful life and to enjoy all the rights and responsibilities of citizenship. It was evident that the manager feels passionate about her role and understands the importance of enabling young people to achieve their goals, aspirations, to be integrated into the community and knows the principles of person centred care. On the day of the site visit the manager was initially not present as she had been asked by the organisation to provide support to a sister home in St Albans. The manager was told of our arrival and came back to Mandalay to meet with us. We were made aware that the manager over the past 2 weeks has been providing support to the other home and is unclear as to how long she will be required to continue doing this. As part of the process we looked at this persons care records and we also looked at a random sample of records relating to support staff and the general running of the home. We also looked at all the information that we have received, or asked for, since the last key inspection, including information under Regulation 37 Notifications. We were made aware by staff during the inspection that since the previous key inspection to the home in 2009, two people who previously lived at Mandalay had left the care home. Staff told us that this was as a result of one persons challenging and inappropriate behaviours increasing to an unacceptable level. We were made aware that an incident occured while out in the community during December 2009 whereby a member of staff sustained an injury as a result of this persons challenging behaviour. We are concerned that we were not notified of this incident or others under Regulation 37. Practices and procedures for the safe storage, handling and recording of medication were examined as part of this inspection and we found that currently the one person who lives at Mandalay is not prescribed medication. We looked at the support plan for the person living at Mandalay. The pre admission assessment was not available at the time of the site visit but was forwarded to us following the inspection by the manager. Information recorded was seen to be basic and it was unclear from the information recorded as to how the decision that the persons needs could be met were determined from the information recorded. The manager confirmed that up until recently the completion of pre admission assessments was undertaken by a person from the organisations head office. We were told by a senior Care Homes for Adults (18-65 years) Page 3 of 10 member of support staff that the service user visited Mandalay on several occasions as part of their transition to the home. No evidence was available to support this as there were no records available detailing the transitional strategy plan or information detailing how each of the visits had developed. The support plan included information relating to the personal details of the service user e.g. date of birth, next of kin information, date of admission, description of the person and the contact details of people involved in the persons care. The latter refers specifically to family, friends and professional support networks. Information relating to the persons preferred daily routine was seen to be informative and person centred with emphasis on the persons strengths, abilities and personal preferences. The support plan was noted to be divided into 14 separate areas relating to the persons personal, emotional, healthcare and social care needs. In general terms the support plan provided good information necessary for staff so as to deliver the persons care, although it would further benefit from being more person centred. Risk assessments were completed and these were seen to be detailed and comprehensive. Each risk assessment recorded the identified area of risk, degree of risk and the identified actions to be taken by staff to reduce the risk. In addition there was evidence to show that weekly keyworker meetings are held where care practice issues pertaining to the individual service user are discussed. Since their admission to the service a review of their placement has been undertaken and this included representatives from the home, the service user and their relatives attending. The outcome of the review is that their placement at Mandalay is proving positive and is currently meeting their needs. A separate healthcare folder is maintained for the person detailing their specific healthcare needs and how these are to be met. The Health Action Plan provides an audit trail of visits to and/or by a healthcare professional. Information recorded includes the name of the healthcare professional or service, details of the visit, outcome and next appointment date where appropriate. Records showed appropriate actions taken by the management team of the home to address the persons healthcare needs and there was evidence of positive links and interventions provided by healthcare professionals. Included within the support plan is a weekly activity plan. This records activities undertaken each day both in house and within the local community. Records showed that the service user is empowered and supported to follow their personal interests, hobbies and daytime activities of their choice e.g. watching films, undertaking personal shopping, going swimming, trampolining, bowling, going to the cinema, having meals out, attending beauty appointments and attendance at local clubs. Daily care records showed that the service user is encouraged and given the opportunity to participate in the day-to-day running of the home and to influence some key decisions within the home e.g. completing their personal laundry, tidying and cleaning their bedroom, assisting staff with the preparation of meals and drinks, menu planning etc. From discussions with the manager it was evident that much thought was given to the choice of key-worker and ensuring there is a positive relationship between both the service user and nominated member of staff. Information relating to how people can make a complaint or raise concerns is available. We were advsied there have been no complaints within the past 12 months. The service user told us that if they had any concerns they would feel comfortable to discuss this with the manager and/or their key-worker. Within the past 12 months there have been no Care Homes for Adults (18-65 years) Page 4 of 10 safeguarding alerts. Staff spoken with know how to respond in the event of an alert and to whom the alert should be raised. We requested to see the outcome of the homes quality assurance surveys since the last key inspection in 2009. No evidence was available to show this had been undertaken by the organisation prior to the appointment of the new manager. The manager told us that satisfaction surveys have been provided to the service user, their family, care manager and independent advocate in May 2010 to seek their views about the quality of the service provided. The manager confirmed that it is her wish in the future for these to be conducted every 6 months. We requested to see the outcome of the organisations monthly visits to the home by a representative of the company. Records showed these are not completed each month as required by regulation and where they are in place information recorded is limited and mainly records Yes or No answers. Records showed that prior to the new managers appointment there was little evidence of staff meetings having taken place but more recently these have occurred and minutes of the meetings were readily available. On inspection of these, records showed in recent months there has been a considerable amount of unrest within the staff team about the previous management of the service, staffing issues and low staff morale. We discussed these issues with the manager and were given assurances that efforts are being made to improve staff morale and to run the home as it should be. A random sample of staff supervision records were inspected and these concurred with information recorded within the staff meeting minutes. The staff supervision records for 3 people were inspected and these showed that staff have not been receiving regular supervision in line with the requirements as detailed by the National Minumum Standards. The manager was advised that further information is required detailing the outcomes from the supervision and who is responsible for actioning these. What the care home does well: What they could do better: Ensure that information recorded within the pre admission assessment is informative and detailed and there is clear evidence so as to determine the needs of the individual person can be met. In addition evidence of transitional visits and the progress of such visits must be recorded. Incidents which are notifiable under Regulation 37 Notifications must be forwarded to us in a timely manner. Information should include details of the incident, people involved, actions taken and outcome. Care Homes for Adults (18-65 years) Page 5 of 10 The registered provider must ensure there is a regular system in place to seek the views of the people who live at the home, their representatives, staff and other stakeholders about the quality of the service provided at Mandalay. The results of the surveys should be collated and an action plan arranged. Regultion 26 visits must be conducted each month by a representative of the organisation and a detailed report compiled. Ensure that all support staff working at the home receive regular formal supervision. A record should be maintained of the supervision detailing the areas discussed, actions to be undertaken and the details of who is responsible for ensuring they are actioned. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Adults (18-65 years) Page 6 of 10 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 34 19 All records as required by regulation are in place. To ensure there is a robust recruitment procedure in place and that people are safeguarded by the homes procedures. Not inspected on this occasion. 03/07/2009 Care Homes for Adults (18-65 years) Page 7 of 10 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 Pre admission assessments must be informative and detailed and provide evidence of the rationale as to how the persons needs can be met. So as to provide evidence that the service can meet the needs of the prospective person. 19/07/2010 2 35 18 All support staff who work at 19/07/2010 the home must receive regular formal supervision. So that staff feel supported. 3 39 26 The registered provider must 19/07/2010 conduct regular monthly visits to the service and prepare a written report on the outcome of its findings. To meet regulatory requirements. 4 42 37 The registered provider must 19/07/2010 notify the Commission without delay any notifiable incident under Regulation 37. Page 8 of 10 Care Homes for Adults (18-65 years) Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action To meet regulatory requirements. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 3 Evidence of transitional visits prior to admission and the progress of such visits must be recorded. Care Homes for Adults (18-65 years) Page 9 of 10 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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