CQC report explained · a residential care home
What the CQC found at Mandalay
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- A potentially life-threatening incident and other significant incidents were not reported to CQC as required. Staffing was sometimes stretched, and some risk assessments and support plans were incomplete, although medicines and infection control were generally managed safely.
- Effective?
- Good
- People's health needs were generally followed up and staff received training and supervision. Inspectors recommended better assessments for pain, sensory needs and oral health.
- Caring?
- Good
- Staff treated people with dignity and respect, understood their communication needs and involved them in everyday choices. People appeared relaxed with staff.
- Responsive?
- Good
- Care was personalised and people had choice and control. Staffing shortages reduced some social opportunities, but staff continued to provide activities and maintain family relationships.
- Well-led?
- Requires improvement
- The provider's systems did not reliably monitor risks, incidents, staff workload or the quality of people's lives. The manager was open and willing to improve, but senior oversight and feedback systems were weak.
What inspectors found, September 2022
Rated Requires Improvement; inspectors found kind, person-centred care but serious weaknesses in incident reporting, risk records and management oversight.
This was the first inspection under the new provider. One inspector visited on 27 January 2022, spoke with staff, managers, relatives and health professionals, observed care, and checked care, medicines, recruitment, risk and quality records.
The home was caring, effective and responsive. Staff understood people's needs, supported communication and choice, and treated people with dignity. Medicines were generally managed safely, and staff worked with health professionals and families.
The home was not always safe or well-led. Staffing vacancies reduced activities and choice. Some risk and behaviour plans were not up to date, and significant incidents were not always reported to CQC or reviewed properly. The provider was asked to improve its governance systems and provide an action plan.
Kind and respectful staff
Staff understood people's individual needs and communication methods. Inspectors saw positive interactions and people appeared comfortable with staff.
“Interactions between staff and people using the service was positive and people seemed relaxed in staffs' company.” from the report
Support for choice
People were involved in everyday decisions about food, activities and who supported them. Staff used pictures, signs and other methods to help people communicate.
“People had choice and control over their lives and were involved in decisions about their care and lived in the least restrictive environment.” from the report
Good medicines practice
Staff were trained to give medicines safely and understood when medicines were needed. Medicines were kept to a minimum and regularly reviewed.
“Medicines were kept to a minimum and regularly reviewed to ensure people were not unnecessarily medicated.” from the report
Useful health and community support
The home worked with families and health professionals to respond to changing needs. People had activities, hospital support and help to maintain family relationships.
“Staff recognised the importance of family and have worked hard to maintain and re-establish relationships with family” from the report
Serious incidents were not always reported
seriousInspectors found a potentially life-threatening incident and hospital admissions that had not been reported to CQC or referred for safeguarding as required. This meant the provider did not have reliable oversight of serious risks.
“During our inspection we identified further concern about a potentially life-threatening incident which was not reported to CQC” from the report
Weak risk and incident oversight
seriousSome risk assessments and behaviour plans were incomplete or out of date. The provider's systems did not consistently identify risks, review incidents or make sure lessons were learned.
“Systems were not used effectively to establish and assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Staffing shortages
needs fixingThere were eight vacancies during the inspection. Staff worked overtime and senior staff sometimes had to provide direct care, leaving less time for management duties and paperwork.
“Staffing levels were at times stretched and variable numbers of staff were on the rota each day.” from the report
Some health records needed more detail
needs fixingRecords did not always clearly explain people's health risks, oral health needs or best-interest decisions. Inspectors made recommendations for more detailed assessments and records.
“Corresponding risk assessments and health care plans were not always in place, which could mean people's needs not being met in a consistent way.” from the report
- 01How many staff vacancies are there now, and how will you make sure people still receive their usual one-to-one activities and preferred staff support?
- 02How do you now make sure every serious incident is reported to CQC and reviewed by senior management?
- 03Have all people's risk assessments and positive behaviour support plans been reviewed and updated since the inspection?
- 04What action has been taken to improve pain, sensory and oral health assessments?
- 05How do you collect and act on feedback from people, relatives, staff and health professionals?
This was the first rating inspection under the new provider and covered all five key questions, including infection prevention and control; the previous Good rating was from 2019 under a different provider. This explanation was written from the published report of 15 September 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Mandalay
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- September 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- September 2017Goodstayed GoodSafe: Inspected but not rated
- September 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2020
Registered with the Care Quality Commission on 13 July 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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13 live-in carers within about an hour of Norfolk
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.