Archived: Mandalay

Updated 23 August 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

This service provides care and support to people living in a ‘supported living’ setting, so that they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post, CQC had been notified of this. An internal clinical governance safeguarding, and quality manager was overseeing the management of the service temporarily until the registered manager’s post had been recruited to. They will be referred to as the manager throughout the report.

Notice of inspection

We gave the service 48 hours’ notice of the inspection. This was because it is a small service and people are often out and we wanted to be sure there would be people at home to speak with us.

Inspection activity started on 27 June 2022 and ended on Thursday 7 July 2022. We visited the service on 29 June and carried out telephone calls to staff and relatives on 30 June and 7 July 2022.

What we did before inspection

We reviewed information we had received about the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspection. We used all this information to plan our inspection.

During the inspection

We spoke with two people who used the service and two relatives about their experience of the care provided. We spoke with four members of staff and the manager.

We reviewed a range of records. These included two people’s support plans and one person’s medicines records. We looked at three staff records and one agency profile, in relation to recruitment, training, supervision. We also reviewed a variety of records relating to the management of the service, including policies and procedures.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We sought feedback from professionals who work with the service.

Updated 23 August 2022

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

About the service

Mandalay is a supported living service providing personal care. Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks relating to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of our inspection two people were receiving personal care.

Mandalay is a purpose-built building with its own individual flats. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care service.

People’s experience of using this service and what we found

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right Support

People received support to follow their own day to day interests. However we found the provider had not always reviewed people’s long-term goals and aspirations or supported people to develop new skills.

People’s risk assessments did not always contain sufficient detail to ensure staff were able to support people consistently and safely. Not all risks had been considered in relation to people's health and social care needs.

People were supported with their medicines safely and in a way they preferred. However we were not assured the providers arrangements for as required (PRN) medicines for people were effective, due to as required medicines not being readily accessible. For example, if a person required medicine for occasional pain or headache.

Right Care

There were sufficient numbers of staff to meet people’s needs and keep them safe.

Staff received a wide range of training to ensure they had the skills and knowledge to support people safely. This included, nutrition and hydration, oral care, professional boundaries, epilepsy, positive behaviour support and learning disability awareness.

Staff promoted equality and diversity in their support for people. People’s specific dietary needs were understood and being met.

People told us staff respected their privacy and dignity when providing care and support.

A complaints procedure was available and displayed to enable people to access it if they or their relatives had a need. We were told no complaints had been received at the time of our inspection.

People were treated with kindness and staff respected their privacy and dignity.

Right culture

People's needs had been assessed and personalised support plans were in place, however, some of this information was inconsistent. People were supported by staff that had been recruited safely, were trained to carry out their roles effectively and who understood people's individual care and support needs.

Audits were undertaken to ensure the quality of the service was maintained, however on inspection we identified risk assessments required more detailed guidance.

People were given the opportunity to provide feedback on the service and, people appeared satisfied. We saw staff well-being and great place to work surveys had been carried out, and relatives told us they were happy with the care and service their loved ones were receiving.

Why we inspected

We undertook this inspection to assess that the service is applying the principles of Right support, right care, right culture.

This was a planned inspection of a newly registered service.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified a breach in relation to safe care and treatment at this inspection. Systems were not always effective to assess monitor and mitigate the risks to the health safety and welfare of people using the service. Please see the action we have told the provider to take at the end of this report.

We have made a recommendation about the management of some medicines.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.