About the service: Mandalay is a residential care home that was providing accommodation and personal care to six people at the time of the inspection.

People’s experience of using this service:

Mandalay has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

All staff interacted inclusively and engagingly with people. The culture of the service was completely focussed on people's individualities and their contribution. The service worked flexibly and innovatively to ensure people who used the service felt at home. Staff were kind and caring and promoted people’s dignity. Staff understood the importance of treating people with respect and ensured they did this. People were observed to have good relationships with the staff team. Staff actively ensured people maintained links with their friends and family.

The risks to the quality and safety of the service were identified and acted on. There was enough staff on duty to enable people to remain safe and receive care in a timely way. The environment was safe and people had access to appropriate equipment where needed. People were supported to take their medicines in a safe way.

Staff had received appropriate training and support to enable them to carry out their role safely. Peoples health was well managed and staff had positive links with professionals, which promoted well-being for them.

Staff were motivated and enjoyed strong team work. The register manager had extensive experience and knowledge in supporting people with complex needs. Staff saw the registered manager as inspirational and a role model to develop their own practice. Information from audits, incidents and quality checks was used to drive continuous improvements to the service people received.

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

Rating at last inspection: Good (Published September 2017)

Why we inspected: This was a scheduled inspection based on our previous rating.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

We carried out an unannounced comprehensive inspection of this service on 12 and 13 July 2016. A breach of the legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements.

This report only covers our findings in relation to those requirements.

The service remains rated as Good overall. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Mandalay on our website at www.cqc.org.uk.

Mandalay provides accommodation and support to a maximum of seven people who are living with a learning disability. The home provides residential care. We focused this inspection on the recruitment checks of staff employed to work at the home. At the time of this inspection, the home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At the previous comprehensive inspection, the registered manager had not ensured that all the required checks had been undertaken, to ensure that staff working at the home were suitable to do so, before they started employment.

At this inspection, we saw that there were effective systems in place since our last visit. The registered manager ensured that all the required checks had been undertaken before staff started working at the home.

This inspection took place on 12 and 13 July 2016 and was unannounced. Mandalay is a residential care home providing personal care and support for up to seven people, who live with a learning disability. On the day of our visit seven people were living at the service.

The home has had the current registered manager in post since July 2010. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Not all recruitment checks for new staff members had been obtained before new staff members started work.

You can see what action we told the provider to take at the back of the full version of the report.

Although medicines were safely stored, the security of medicines was at risk and this meant that there was a risk of unauthorised access which could place people at risk. Medicines were safely administered, and staff members who administered medicines had been trained to do so. Staff members received other training, which provided them with the skills and knowledge to carry out their roles. Staff received adequate support from the registered manager and senior staff, which they found helpful.

People’s relatives felt that people were safe living at the home and staff supported them in a way that they preferred. There were enough staff available to meet people’s needs and additional staff were available if required.

Staff were aware of safeguarding people from the risk of abuse and they knew how to report concerns to the relevant agencies. Individual risks to people were assessed by staff and reduced or removed. There was adequate servicing and maintenance checks to fire equipment and systems in the home to ensure people’s safety.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service was meeting the requirements of DoLS. The registered manager had acted on the requirements of the safeguards to ensure that people were protected. Staff members understood the MCA and presumed people had the capacity to make decisions first. Where someone lacked capacity, best interests decisions had been made.

People enjoyed their meals and were able to choose what they ate and drank. Staff members worked together with health professionals in the community to ensure suitable health provision was in place for people.

Staff were caring, kind, respectful and courteous. Staff members knew people well, what they liked and how they wanted to be treated. People’s needs were responded to well and support was always available. Care plans contained detailed information to support individual people with their needs. They provided staff with guidance about behaviour that may challenge or upset others, what to do and what not to do, and how to do this in a positive way that helped people rather than restricting them. People’s relatives said that people were happy at the home and that they developed skills and abilities while living there that they had not previously had.

A complaints procedure was available and relatives were happy that they did not need to make a complaint. The manager was supportive and approachable, and people or other staff members could speak with her at any time.

The home monitored care and other records to assess the risks to people and ensure that these were reduced as much as possible and to improve the quality of the care provided.

People told us that staff members obtained their consent before supporting them with care or treatment. Care records recorded which decisions people were able to make for themselves and which decisions they did not have the capacity to make.

People received the care and support they required to improve their health and well-being. Risk assessments and care records were written in detail and provided clear guidance to staff members, and evaluations of care plans were completed.

Medicines were stored appropriately and records were maintained to show all storage areas were kept at the correct temperature. Administration records were kept and people received their medicines in a safe way.

The service had a policy and procedure to guide people in how to make a complaint but there was inadequate information about taking complaints further. We observed that staff members took people's concerns seriously, even if they were not able to easily identify the nature of the concern or resolve it.

During our inspection of 05 November 2012 people told us they liked living at Mandalay. We saw that people were encouraged and supported by staff members to live as independently as possible. Records examined demonstrated to us that people's views and experiences were taken into account when planning care and support with them.

We saw that people's care needs were identified with them on initially taking up residence at the home. Care needs were then regularly reviewed with people to ensure staff members were able to provide appropriate care and support to them.

Staff we spoke with demonstrated a clear understanding of safeguarding vulnerable adults guidance and procedures.

Staff members we spoke with told us that they felt well trained and supported to provide appropriate care and support to people using services at Mandalay.

We saw that there were effective systems in place to assess and monitor the quality of services provided at the home.