Mandalay

Updated 24 January 2024

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 1 inspector.

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 provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post, however they were also the Regional Director and were not overseeing the service on a daily basis, this was managed by a Senior Operations Manager who was providing interim cover for the service. We will refer to them 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 we needed to be sure that the provider or registered manager would be in the office to support the inspection.

Inspection activity started on 20 November 2023 and ended on 06 December 2023. We visited the location’s service on 21 November 2023.

What we did before the inspection

The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We reviewed information we had received about the service. We sought feedback form the local authority. We used all this information to plan our inspection.

During the inspection

We received feedback from 1 person who used the service and 2 relatives about their experience of the care provided. We received feedback from 3 members of staff and spoke to the manager, a senior operations manager, and the registered manager. We reviewed a range of records. These included 2 people's support plans and medicines records. We looked at 2 staff records and 3 agency profiles, 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.

Updated 24 January 2024

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. The service can support up to 6 people.

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

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.

Right Support:

People’s risks had been identified and assessed however, these required further improvement to ensure they were individualised to the person. We have made a recommendation around reviewing the management and updating of risk assessments for people. Staff had received training and were in the process of attending further specialist training to further develop their skills and knowledge. Where we identified gaps in agency staff training the manager liaised with the agency to ensure training was completed. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. We have made a recommendation about the completion of MCA documents. The service had a manager who was overseeing the day to running of the service and they were working with the staffing team, people, and their relatives to improve communication and build positive relationships.

Right Care:

People and their relatives told us they felt supported by staff in a kind, caring and dignified way. People's differences were respected by staff and people's relatives told us the care and support provided was consistent and by staff who knew them well. People's right to privacy was respected and staff encouraged people to regularly provide feedback through monthly meetings. Support plans included information on people's healthcare needs, preferences, goals, aspirations, and hobbies, however, they were difficult to navigate due to their size and content, information did not always triangulate across all areas of the support plans, so information was not always current.

Right Culture:

The culture of the service was open, inclusive, and staff were committed to supporting people to live as independently as possible. Improvements were required regarding the oversight of the service. Management needed to develop an effective auditing system to have a more robust oversight of the service and identify issues where learning is then embedded, and continued improvements can be made. People and their relatives felt their ideas and concerns would be listened to by management. Staff were complimentary about the new provider and felt there had been a positive improvement in communication and the management of the service. Staff told us they felt supported, and they were able to raise concerns with managers, and were confident any issues would be resolved.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The last rating for the service under the previous provider was requires improvement, published on 19 August 2022.

Why we inspected

This inspection was prompted by a review of the information we held about this service and to assess that the service is applying the principles of Right support right care right culture.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment and good governance. Systems were not always effective to do all that is reasonably practical to assess monitor and mitigate the risks to the health safety and welfare of people using the service.

We have made a recommendation around the providers management of reviewing and updating risk assessments for people. Providing more detail around the decision making process when completing mental capacity assessments and ensuring people's support plans are reflective of their care and support needs and are regularly reviewed.

Please see the action we have told the provider to take at the end of this report.

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.