Madeira Lodge

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

People were not always protected from avoidable harm because risk assessments were not always clear, comprehensive and up to date. They did not always contain enough information about people’s risks and mitigation strategies for staff to provide safe and effective care. This was a continued breach of Regulation 12 (Safe care and treatment). Staff and leaders were able to identify situations that amounted to safeguarding and staff were confident to use the whistleblowing process if needed. Staff knew people well and were able to identify changes to health and identify care and support needs. Lessons were learned when things went wrong, however actions to embedded the lessons learned were not always robust. Medicines were administered and recorded safely. Medicines policies had not always been followed by staff in relation to administering PRN (as and when required medicines). Staff were recruited safely. Some staff had not completed all the relevant training to be able to meet people’s needs safely, this was an area for improvement. There was a plan in place to make sure staff had ongoing support in the form of supervision and appraisal meetings. There were enough staff to support people safely. Accidents and incidents were reviewed and actioned by the management team, safety checks undertaken by staff. The provider worked with people and partners including local authority care managers and health professionals to establish and maintain safe systems of care. The provider had systems and processes in place to detect and control potential risks in the care environment and processes in place to assess and manage the risk of infection. We were assured that the provider was working to improve safety through the layout and hygiene practices of the premises.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We could not be assured that people benefitted from a service that learned lessons from incident and accidents and put measures in place to reduce the likelihood of these reoccurring. This is because there was no record of the analysis and actions. Relatives told us they were kept well informed when there were incidents, changes or concerns. A relative said, “They keep me informed all the time if anything happens. He went into hospital and he was more than happy to go back there.”

The registered manager told us lessons learned were identified during investigations and they did a reflective practice with individual members of staff, where appropriate. These records were retained in their files. Verbal and written feedback to the teams was via memos, at meetings, during handovers and using the internal messaging system which enabled the manager to identify any staff who had not read the information. Staff told us they felt confident to report any incidents or raise concerns and were confident that the appropriate actions would be taken. Staff were fully aware of the accident and incident reporting procedure and records confirmed that staff documented these appropriately. A staff member said, “We have put sensor mats in place for one person when they fell, and all incidents are reported onto the system.”

Accidents and incidents were recorded on the provider’s care planning systems and the information was transferred to another system so that trends and patterns could be identified, and appropriate actions taken. Managers had access to a dashboard of information giving them an oversight of important events such as accidents, incidents, health checks and weights. It was not clear from the providers documentation what actions were being taken to address identified trends, for example, that most accidents and incidents happened in the afternoons and evenings. Safety checks undertaken by staff including maintenance, were audited and checked by the management team. This enabled the management team to make continuous improvements. However, following a recent medicines error, whilst an account had been written about the incident, a reflective practice had not been completed by the member of staff involved. This would support good practice guidance. One of the areas the provider identified that they could do differently was to put photographs on the boxes containing the medicine. At the time of our assessment visit, this had not been implemented. This medicines incident had not been included on the provider’s continuous improvement plan. There was no evidence that anyone had been harmed as a result of this incident.

People were supported to maintain their health, attend appointments both inside and outside of the service. Where routine health checks were undertaken people had support from people who they know well to understand what was happening. A relative told us, “Chiropodist does come on a regular basis, GP [visits] as needed.”

The management team explained that they worked with others to resolve problems and make improvements. The service had maintained regular contact with local authority social workers. As well as ongoing work with the GP and home visiting team. Staff told us people received visits from other health professionals. On the day of our visit, one person was visited by a health professional from the memory clinic.

A healthcare professional told us, ‘The Home Visiting Team have a dedicated email for all the care homes in the area. We ask that care home ward rounds are submitted by email before 11am to ensure that visits can be facilitated the same day. Madeira Lodge are quite often late with ward rounds and more recently they have completed ward rounds with misspelled names and wrong dates of birth, this makes the process of arranging care home visits more difficult. Often, staff at Madeira Lodge will ask for treatment rather than a visit, although when we triage the ward rounds, we will advise them if a visit is more appropriate. We have devised a flow chart that they should be following to support their decision making; but have also had to advise them to call ambulances when ward rounds have been sent inappropriately, and the patient clearly required urgent care. The Home Visiting Team do understand that patients can become unwell at all times of the day, however when the ward rounds are consistently late it also makes it very difficult to triage and allocate visits.’

The provider had systems in place to work with people and partners including local authority care managers and health professionals to establish safe systems of care. Safety was managed, monitored and assured. When people were supported to go to hospital, either through routine and planned admission, emergency admission or consultation day visit, hospital passports were in place. A hospital passport helps people to give hospital staff important information about them and their health when they go to hospital.

People did not always feel safe and protected from harm. People gave us examples of incidents and altercations that had occurred. Comments included, “I don’t feel safe here”; “I don’t feel safe when [person] starts to get angry and shouting. I try to keep out his way. I was in the army for 22 years and can look after myself if he thumps me, I will dock him one. I can’t always be there to keep other people safe.” Some other people told us they did feel safe. A relative told us about a situation where their family member had not been protected from harm. They explained immediate action had been taken to ensure their family member was safe from further harm. They told us, “The incident would have affected [person] greatly. We are grateful that fast action was taken.” Staff were attentive to people’s needs and made sure they were safe as they carried out their daily routines. Relatives told us they were confident to raise any concerns and knew that they would be responded to.

Staff had received adult safeguarding training and had refreshers every year. A staff member said, “We have on-line safeguarding training every year. It involves watching a series of videos and then answering questions for each scenario.” Staff understood their responsibilities to report a safeguarding concern. Staff were similarly aware of whistleblowing and were confident to speak up if needed. A staff member said, “I feel very confident to raise anything of concern.” The nominated individual for the provider told us, the provider selected a policy of the month for all staff to read and confirm that they have read by signing. This ensured there were regular refreshers on policies and the staff remained up to date with their training.

We observed interactions between staff and people during our visit. We saw safe practice whilst enabling people to maintain their routines and come and go around the service as they wanted. Most people required physical support to move around the service.

Safeguarding and whistleblowing policies were in place and were accessible to staff. Staff were aware of the whistle blowing policy and told us they had access to all policies at all times. The provider had safeguarding children from abuse policies in place which specified it would provide safeguarding children training to staff. Safeguarding training did not include safeguarding children. This meant staff did not have all the information they needed to keep children safe. The service had frequent visits from children. Safeguarding concerns had been reported appropriately. The management team told us they had positive working relationships with the local authority and other statutory partners and were confident to seek advice and report safeguarding issues in a timely way. The management team had reviewed processes and learnt lessons from safeguarding incidents.

People and relatives gave us mixed views about how staff managed risks. A relative told us, “He has had several incidents there and has been attacked by other residents and the staff were very good, they told me right away and made him safe as soon as possible and they kept up to date with everything going on and how they would prevent it happening again.” Another person’s relative told us that risks from recurrent urine infections were not always picked up when signs and symptoms were showing. They detailed their relative was displaying signs during the assessment. They alerted staff of this as staff had not identified this. The service used equipment to help maintain people’s safety. A relative told us, “They move him safely with the hoist.”

Staff told us they knew people well. They understood their risks and knew how to keep most people safe. When people became distressed and emotional staff knew how to manage these situations and to stop people hurting themselves or others. The service did not subject people to restrictions, such as bed rails. Other measures were in place to protect people who were at risk of falling, such as low rise beds and sensor mats.

We observed that risks were not always well managed. People were supported to move around the service safely and were supported to spend time where they chose. People were not always given food and fluid in a consistency which was in accordance with their assessed needs. Staff checked on people eating in their rooms to make sure they were eating and were safe.

Risks to people were not always identified and risk assessments lacked enough detailed information for staff to know how to keep people safe. For example, a person who had experienced 2 choking episodes requiring emergency intervention in 2024 had been deemed not to be at risk of choking. This was based on an assessment by the Speech and Language Therapists (SaLT) 3 months before the first choking episodes which stated normal food and fluids. There was no evidence the person had been referred to the SaLT team following either of the choking episodes. Staff told us they had a telephone assessment, but there was no evidence this had happened. There was discrepancy between staff members about the level of risk and any actions required including food consistency. During our inspection this person was eating normal consistency food and was seen to be coughing throughout the meal experience. In other cases, risk assessments were comprehensive and contained a good level of detail with instructions for staff to support them to keep people safe from their risks. For example, risk assessments for people on blood thinning medicines had very detailed risk assessments in place, which included details of complications, what staff should be observing for and what actions they need to take. A person’s risk assessment and care plan mentioned triggers to them becoming agitated and upset. It detailed how the person presented themselves when they were agitated and detailed what staff could do to mitigate the risks. It also detailed what actions staff should take if there were incidents. For example, the care plan states that taking the person into the garden, offer tea or food or call their family had been known to help in the past. Incident records reviewed, did not evidence that staff had tried any of these actions. Diabetes risks were not always well managed. A person's blood sugar levels had been extremely high and insulin has been given at erratic times.

People benefitted from an environment that was maintained and clean. Radiators were covered, which reduced the likelihood of people sustaining burns from access to hot surfaces. There were window restrictors to all windows. The corridors were light and unobstructed. Toilets and bathrooms were clean, sanitised, and fresh, with pull cord alarms in accessible and in reach. A relative told us, “They have been decorating, there has been new furniture, standards are high.”

The registered manager told us when a new television had been received it will have a cabinet built round it to prevent any future damage. They detailed that if anyone wished to watch television whilst the large television was broken, they were able to use the activity lounge for this.

A redecoration programme was in place, some rooms and areas had yet to be completed. Some of these areas looked tired. The large television in one lounge was not working as it had been damaged and smashed by a person during an episode of distress. The television no longer worked and had been added to the maintenance team job list. They had not yet removed the television as it had been assessed as safer to leave the damaged television in place until a replacement arrived. Other maintenance tasks appeared to have been completed in a timely manner. Rooms were clean and tidy and had been personalised in accordance with the person’s wishes. Fire exits were clearly visible and unobstructed. Evacuation sledges were clean and hung on the walls upstairs to aid evacuation if required. The lift was clean and in working order.

The provider had systems and processes in place to detect and control potential risks in the care environment. This made sure that the equipment, facilities and technology supported the delivery of safe care. Essential servicing and maintenance of the gas, electric, lift, fire alarm system, emergency lights, moving and handling equipment had taken place.

People gave us positive views about whether there were enough staff on duty at the service. A person told us staff “Know what they are doing. These people are really good here they really are [pointed at staff].” Another person told us, “They come quickly when the button is pressed.” A relative told us, “New staff in post are good.” Other relatives said, “They always seem to have enough staff on duty and staff recognise me and are friendly” and “There are a lot more staff now. It has improved.” A regular visitor told us, “There are enough staff and they work hard.”

Staff gave us mixed feedback about whether there were enough staff on duty to provide safe care. A staff member said, “I do think there are enough staff but if someone calls in sick or a person needs more support with lifting/handling, or is having a bad time, that can have an impact.” Another staff member told us, “There could be more staff now that there are more people who have hoisting needs.” Staff told us about the training and support that provided them with the skills they needed to support people safely. Training was provided online as well as face to face, depending on the topic. A staff member said, “The training is good, mainly online although we had one nurse visit us recently to talk about a particular type of cancer and what to look out for, and she left us leaflets. We get reminders by email when training needs to be done and updates on training when there has been new guidance.” A staff member said, “I can’t remember the last time I had supervision, but I think it’s 3 monthly. It’s good because it gives me a chance to speak up about anything.”

We observed there were enough staff on duty to support people. Call bells were answered quickly. Staff were interacting politely and respectfully with people. A person started to become more vocally agitated and staff responded to calm and reassure them. Staff got down to eye level, held their hands and explained that their family were visiting shortly. The staff member stayed with them until they were calmer.

Staff had been safely recruited. We examined 3 staff files and all of the required checks had been carried out and documents were all in date. In files we saw copies of references, interview notes, photographic identification and Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff had supervision meetings and induction was a mixture of training and shadowing experienced staff to gain confidence and experience. However, the provider’s training matrix showed that some staff had not completed mandatory training relevant to their roles. For example, only 33 out of 45 staff had completed training in behaviours that challenge and only 26 out of 45 had completed dementia training. Following the assessment, we received information from the provider that the staff had been booked on to these courses. The provider's training records showed only kitchen staff had completed allergens training when all care staff supported people with meals. The nominated individual for the provider told us that care staff received allergen training within their food hygiene training. There were enough staff deployed on shift during the assessment to meet people’s needs and provide safe care. The service used a dependency tool, this had been updated monthly, which helped the manager to calculate the number of staff needed.

People told us their bedrooms and the service were clean and tidy. A person told us, “A cleaner comes and cleans the room and my laundry is done.” Relatives gave us mixed views. They said, “Very clean and no smells, I have seen a cleaning lady with the cleaning trolley, it happens when people are up and in the lounge”; “There are a couple of cleaners, but I think it is done in the morning, it seems to be done before we go. It never looks dirty, sometimes the tables are dirty” and “It’s not particularly clean [pointed out to dried food trodden into the floor], there is a brown substance on handles some time. The cat is very smelly and shut in a room.” The nominated individual told us that the cat stays upstairs and in the hallway. There is a risk assessment in place for the cat and there is a cleaning schedule and food chart in place for the cat.

Staff told us they had sufficient equipment and PPE (Personal protective equipment) to provide safe care. Staff had received infection prevention and control (IPC) training and were familiar with IPC processes to mitigate infection risks.

We observed that the staff were using PPE effectively and safely. The provider was promoting safety through the layout and hygiene practices of the premises. There were no restrictions to visitors. We observed visitors coming and going freely during the assessment. We observed relatives noticing their family member’s slippers were dirty and taking time to clean these off. The person had been with staff for some time prior to this and this had not been noticed.

The provider had systems and processes in place to assess and manage the risk of infection. They were able to detect and control the risk of it spreading and share any concerns with appropriate agencies promptly. The provider had a daily cleaning program in place. The service employed housekeeping staff to carry out daily cleaning, cleaning schedules were in place which included deep cleans for people’s rooms. Infection control audits were completed regularly and actions taken if any issues were found. The provider had plenty of PPE in place to keep people and staff safe. The kitchen areas were clean and well managed.

People received their medicines safely. A person told us, “Staff give me medicines when I need them.” A relative said, “They manage his medicines.” We observed the staff were polite, gained consent, and recorded the administration of medicines on the electronic medicines administration record (MAR). Creams and bottles were labelled with the date of opening to ensure they remained suitable for use. For medicines administered either via a skin patch or injection, the site was recorded each time to ensure the person’s skin did not become irritated.

People received their medicines from trained staff. The staff informed us they received training. The management team told us staff were competency assessed to handle medicines safely. People were supported by the local GP and frailty nurse. The manager told us there was a keypad lock on the door to the medicine room to prevent unauthorised access. Only senior care workers had access to the medicine room. Recording of medicine administration was done on an electronic system and each individual staff member trained to administer medicines had their own log in. The manager told us they completed weekly and monthly medicine audits and random spot checks. Staff administering medicines were required to stay with the person to ensure the medicines has been taken. If a person refused their medicines this was documented and the medicines disposed of safely. This is detailed in each person’s medicines plan and has been implemented since a recent medicine error.

The provider had systems and processes in place to manage medicines, these were not fully robust and some improvements were identified. For medicines given ‘as required’ (PRN), such as pain relief there were protocols in place. The reason for administering lacked detail and was vague in places, for example, ‘agitation’. The medicine administration system did not appear to support the recording of the effectiveness of the medicine; therefore, the outcome was not recorded consistently. This could lead to people being given PRN medicine that is not effective and there was a lack of audit trail on which the GP could make a judgement about its effectiveness. Room and fridge temperatures were recorded daily to ensure medicines were stored at the correct temperatures. Cupboards were locked and controlled medicines were stored in accordance with national guidance. Medicine trolleys were locked and were securely attached to the wall. Medicine trolleys were organised with each person’s name on the front of the box containing their medicines. Boxes did not have photographs of people on them despite this being deemed a suggested improvement following a medicines error.