Mandalay

Right support: • Staff mostly supported people to maximise their choice, control and independence. During this inspection we found staff focused on people's needs and ensured they had a good quality of life. Recent changes in people's needs were identified and acted upon. Staffing levels had been a challenge for the service over the last year or so. Both as the result of the COVID 19 pandemic but also for other reasons. Staffing levels had not impacted on people's care but had reduced people's opportunities and choice. For example, the regularity of one to one activity had diminished and one person required at least one male member of staff to support him and this had not always been possible.

Right care: •Staff involved people as far as possible and communication and positive behaviour plans described how staff should support people appropriately and reduce any anxiety or frustration they might experience. However, at the time of a recent significant incident the persons positive support plan was not up to date. Care was person-centred, and staff understood people's needs well and adapted their approach to each individual. People were supported to make decisions.

Right culture: •A recent whistle blowing concern was properly investigated by the provider, and lessons learnt from this specific incident. This helped to ensure the concerns highlighted were not duplicated and people and staff were fully protected. We found, however, that an underreporting of incidents had resulted in poor provider oversight. We also identified significant incidents which had not been reported to CQC as required. We were therefore not confident of the provider oversight over a longer period of time.

Staff spoken with demonstrated they had the right ethos and values and pulled together to support each other appropriately. Staff were aware of the role of external agencies in keeping people safe and felt able to

raise and act on concerns. Staff had confidence in the registered manager. Staffing shortages had meant staff worked longer hours including overtime and senior staff did not have time to complete all their duties as they were required to work on shift and prioritise people's needs. The employment of temporary agency staff was being considered to reduce staff's workload. Staff did tell us they felt well supported and received regular training, support and supervision to do their jobs.

The environment was suited to purpose, but some improvements had been identified and some improvement had been made whilst others were still outstanding. An extensive fire report had been completed, which made a number of recommendations which had been actioned. The staff communicated well with family members, health care professionals and wider members of the community to give people as full as life as possible.

People's medicines were kept to a minimum because staff understood people's needs and could often deescalate a situation before alternative interventions such as medicines were required.

People's health care needs, and medicines were effectively managed, but we have made a recommendation about assessments to ascertain people's needs in the following areas: Sensory needs, Pain threshold where people cannot verbally express this and oral health assessments.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.