29 June 2022
During a routine inspection
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.