CQC report explained · a residential care home
What the CQC found at Mandalay
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that infection prevention and control measures were in place. This included safe visiting, social distancing, admissions, protective equipment, testing, cleaning and outbreak management.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Requires improvement
- This question was not assessed in this targeted inspection.
- Well-led?
- Good
- This question was not assessed in this targeted inspection.
What inspectors found, February 2021
Inspected but not rated; inspectors were assured that infection prevention and control arrangements were safe.
This was a targeted inspection on 15 January 2021. It focused only on infection prevention and control during the COVID-19 pandemic.
Inspectors found good practice. Staff adapted support to people's individual needs. Consistent staff were used when usual staff were unavailable, which helped reduce distress.
Inspectors were assured about visitor safety, shielding, social distancing, admissions, personal protective equipment, testing, cleaning, the building layout and managing outbreaks.
The home was inspected but not rated. This means the inspection did not give an overall quality rating or full ratings for the five questions.
Personalised safety support
Staff adapted their approach to people's individual needs and supported them in a personalised way.
“Staff supported people in a personalised manner to remain safe, adapting their approach in line with each person's needs.” from the report
Consistent staff
When usual staff were unavailable, the provider used consistent staff. Temporary staff had got to know people well, helping to reduce distress during the pandemic.
“The new temporary staff had got to know people well, which had helped minimise distress from the COVID-19 pandemic.” from the report
Suitable layout and cleaning
The home was easy to clean and its layout allowed people to be isolated, with dedicated personal areas.
“The layout of the building meant people could be easily isolated, with each person having a dedicated area for their personal use.” from the report
Infection control measures
Inspectors were assured about the arrangements for visitors, social distancing, protective equipment, testing and managing outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing visits and preventing visitors from catching or spreading infections?
- 02How do you make sure people receive support from consistent staff when usual staff are unavailable?
- 03How are staff and people using the service being tested?
- 04How are personal protective equipment, cleaning and social distancing arrangements being maintained?
- 05How would you isolate people safely if there were an infection outbreak?
This was a targeted inspection of infection prevention and control and Safe only; it was not a full assessment of the other four questions or an overall rating. This explanation was written from the published report of 12 February 2021 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.
What inspectors found, May 2018
Mandalay was rated Good overall, but inspectors found that people were not always supported to develop fulfilling lives and independence.
Inspectors made an unannounced visit on 5 March 2018. They spoke with people living there, staff, a family member and professionals. They observed care, checked three care records and reviewed management documents.
The home was rated Good for being safe, effective, caring and well-led. Inspectors found enough safely recruited staff, good medicines support, caring relationships and improved management. Staff understood people's needs and supported their health, choices and privacy.
Responsive care was rated Requires Improvement. People did not always have clear goals for their future, activities were often repetitive and care plans were not always accessible in people's preferred communication formats. Reviews and family feedback had also not been consistent.
The overall Good rating remained unchanged from the previous inspection. The report says there was room for improvement but no evidence of serious risks or concerns.
Safe staffing and risk management
There were enough staff to meet people's needs, including one-to-one support where required. Staff had clear information about risks and how to reduce them.
“We observed there were enough staff to meet people's needs.” from the report
Kind and individual care
Staff knew people well, supported their choices and treated them with dignity. Inspectors saw relaxed and comfortable relationships between people and staff.
“We found people continued to be supported by caring and compassionate staff.” from the report
Improved leadership
The new manager had improved staff morale and introduced stronger audits and action plans. The report describes a more open culture and better oversight.
“The provider had recruited an extremely experienced and knowledgeable manager who demonstrated excellent management skills and was driving improvements in all areas.” from the report
Health and daily choices
Staff helped people access health professionals and supported them to choose what they ate and drank. Mental Capacity Act and DoLS responsibilities were being met.
“People were able to choose what they ate and had access to plenty of fresh fruit and vegetables.” from the report
Limited activities and future goals
needs fixingPeople were not always supported to develop aspirations, independence or fuller lives. Inspectors found repetitive activities and limited attendance at structured activities.
“We found people did not always lead fulfilling lives, with clear objectives for developing their aspirations and independence.” from the report
Care plans and reviews
needs fixingCare plans were personalised but not adapted so people could access them in ways suited to their communication needs. Reviews had also become inconsistent after management changes.
“Care plans were fairly uniform in style and had not been adapted to be more accessible to the people who used the service.” from the report
Family feedback and communication
needs fixingThe home had not formally recorded feedback from families or communicated with them well during a period of disruption. Inspectors said this had improved under the new manager.
“There was not a formal record of feedback from families, despite the increase in concerns during 2017.” from the report
Environment and garden
minorThe property was clean and homely, but inspectors said its decoration and garden could better reflect residents' interests and needs.
“The garden was pleasant but had not been developed attractively in line with the interests and needs of the people at the service.” from the report
- 01How does the home now set and review meaningful goals for each person’s interests, independence and future aspirations?
- 02What activities are currently available, and how do you avoid residents having a repetitive weekly routine?
- 03How are care plans made accessible to each person’s communication needs?
- 04How often are care plans reviewed, and how are families involved in those reviews?
- 05What feedback do you collect from families, and how do you show that concerns lead to changes?
This was an unannounced inspection covering all five CQC questions, with evidence gathered from people, staff, a family member, professionals, care records and management documents. This explanation was written from the published report of 18 May 2018 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
3 rated inspections over 3 years: the service has held its Good rating throughout.
- February 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- May 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- August 2016Goodstayed GoodResponsive: GoodWell-led: Good
- August 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Registered with the Care Quality Commission on 1 July 2014.
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.
Weigh the report against the rest
Fees, photos and reviews from families
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35 live-in carers within about an hour of Essex
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 £1,020 to £1,260 a week. 25 can care for a couple. 10 years' experience on average.
“Not only was she professional, polite and efficient but she bought a lovely smile and laughter to my parents home.”
“She brought fun and stimulation into mums life.”
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.