Madeira Lodge

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The management team told us, that they and the service were looking at ways to continually improve. Accident, incidents, complaints or other significant events were logged on an electronic system. The system automatically produced output relating to trends and patterns to support managers to take appropriate actions and to share lessons learned. However, there was little evidence that actions had been taken in response to analysing the trends and patterns. Systems and processes to audit and check the service were in place, however these were not always robust. This was a continued breach of Regulation 17 (Good governance). Leaders proactively supported staff and collaborated with partners to improve the service and improve the quality of care being delivered to ensure it was safe and person-centred.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The management team were clear they wanted to improve the service and outcomes for people both in their experiences and the environment. The registered manager had worked hard with staff at all levels since the last inspection to improve the culture of the service. Staff reported a positive open culture where they felt empowered to raise any concerns or make suggestions.

The provider and the manager had kept up to date with local and national developments within health and social care and had attended forums, training and signed up to well known, reputable websites to find advice and guidance such as Skills for Care. Skills for Care supports adult social care employers to deliver what the people they support need and what commissioners and regulators expect. The service has a continuous improvement plan in place to ensure shortfalls were addressed. The manager used opportunities to gather feedback from people, relatives and staff. There were regular meetings with all groups of people and participation and comments were encouraged. Staff told us the manager had an open-door policy. Recruitment activity had improved recently, and use of agency staff had declined. Handover meetings were held daily and documented on the care management system. Daily multidisciplinary team meetings had lapsed recently but the registered manager intended to start these up again soon.

The management team knew people well and were passionate about making changes to improve people’s lives. There was a clear management structure in place with a registered manager supported by a deputy. Senior care workers supported the care workers on a day-to-day basis. Staff understood their responsibilities to meet regulatory requirements. The registered manager was supported by the provider and a compliance manager visited the service regularly to undertake checks and audits. The management team told us they were well supported by the provider.

There was a continuous improvement plan in place that took actions from various sources, such as professionals visits or inspections, quality team visits or audits. The plan was reviewed and updated weekly and could be accessed by senior managers who monitored the completion of actions. Some actions had passed the deadline date but the date had not been updated to reflect any new time scales. The nominated individual for the provider told us, 'Dates will be updated once staff receive timeframes from external contractors.' They explained staff were dependent on updates from third parties. We noted that the plan had not been updated to reflect that external contractors had been chased up.

Staff confirmed they were invited to meetings and encouraged to contribute. Staff meeting minutes evidenced that these took place regularly. Staff were encouraged to voice their ideas for improvements and any concerns. Staff knew how to raise concerns with the provider or outside organisations if they needed to. A staff member said, “There is also a website address and telephone numbers to speak to people outside the organisation if you want.”

The provider had systems and processes in place to foster a positive culture where people felt that they could speak up and have their voices heard. Complaints processes were available. Relatives told us, “Since [registered manager] has taken over things have improved”; “There’s been a lot of change, [registered manager and deputy manager] are brilliant, always happy and smiling and their door is open, they listen to problems” and “We had a concern and that was dealt with.”

Staff told us they were treated fairly and equally by managers and their colleagues. Staff were supported if they had any personal issues affecting their work. The provider deployed a diverse workforce and encouraged a culture of teamwork, respect and cooperation. A new staff room had been created at the service to give staff their own space. There was an employee of the month scheme in place where staff could be nominated by managers, colleagues, people or relatives. Staff received a certificate and a financial reward. Staff had access to a confidential personal support line if they needed any help with issues such as mental health or bereavement.

The provider had processes in place to ensure there was an inclusive culture. Staff said the culture of the service was open and inclusive and they all worked together well as a team. The workforce was diverse and support was in place for staff. Staff were invited to meetings each month and at least two thirds of the staff attended. For those unable to attend the notes were sent to them. All staff had to acknowledge they had read the meeting notes. Meeting attendance was reviewed at supervision sessions.

Staff told us they liked working in the service and the manager and provider were supportive and approachable. Staff we spoke with were confident that they could discuss any concerns with the management team and these would be acted on, they were aware of how to escalate concerns to senior management or outside of the organisation. A staff member said, “I feel happier working here than I ever have.” Another member of staff said, “Since [registered manager] and [deputy manager] have taken over, you can go to them about anything at all and they deal with it.”

Since our last inspection the provider has made the audit process more robust. Audits were being done more regularly and the registered manager had made the content of the audits more thorough. There were monthly audits of infection control, care plans, medicines, kitchen, weights, falls and wounds; and health and safety audits were three monthly. There was a resident of the day process which ensured each person had a full review of their care and support plans. There was a trend analysis in place so the provider could identify patterns of incidents and take the appropriate actions to minimise the risk of repeated occurrences. Although these processes were in place, they were still not robust enough to highlight and manage shortfalls in the service. For example, the audits had sections for action plans and although shortfalls were found in some audits, all the action plans were blank. The audit was designed to have formulas to calculate scores which could be used as an improvement tool, but these formulas were not working. Some areas of the audits were scored positively; however, this did not always match the findings during our inspection. For example, ‘Does the care plan detail any choking risks’ and ‘Are choking risk assessments in place for people under the care of the speech and language therapists’, were both answered ‘yes’. However, we identified a person at risk of choking who did not have a choking risk assessment in place. The question, ‘Do hygiene charts evidence resident’s basic care needs’ was answered yes. However, we identified people who had not been offered a shower and there was very limited recording of oral health care. The question, ‘Do the meal charts describe what the resident has eaten’ was answered yes, but this was not the case in the records reviewed during the inspection.

People and relatives told us about visits to the service from community nurses and other healthcare specialists. People told us they don’t get out of the service into the local community as much as they would like. Comments included, “I’d like to go to the garden. The first day I came here they said they’d take me to the beach, I did go. It is beautiful. I’m still waiting to go the pub” and “I feel restricted here. I’d like to get out more. I go for walks with staff and I have been to the beach to see the tanker.” A relative said, “I would like it if he could go out in the garden but he escapes.” A person told us, “I do like to go to church at Christmas and I have been with them here to listen to carols at the local school.”

The registered manager told us they were working closely with the community hub and dementia cafes to foster better relationships and reputation within the local areas. All staff worked with visiting health and social care professionals. Staff explained how they welcomed visitors and visitors. The service welcomed community groups and visiting clergy.

The local authority quality commissioning team told us they had been working closely with the new management team at Madeira Lodge to make improvements at the service.

The provider had systems and processes in place to collaborate and work in partnership with health partners, social services and local authority contracting teams. This enabled them to share information and learning with partners and collaborate for improvement. The local authority had been to visit the service 2024. The service had raised funds and donated to local schools and were working with local schools to create some artwork for the perimeter fences. Each month the service welcomed external entertainers and there was a weekly visit from a local church.

The management team told us, that they and the service were looking at ways to continually improve. A variety of meetings were organised by the registered manager. Staff were invited to meetings monthly and encouraged to contribute. Staff told us they had regular supervision sessions with a manager or senior member of staff. The registered manager met every three months with people and relatives, although these are mainly attended by the same people. The registered manager has offered alternative dates and times, but attendance has not increased significantly. Other meetings held on an ad hoc basis include senior care worker meetings and kitchen staff meetings. Relatives told us they had seen improvements. A relative said, “The change is wonderful, we have seen more changes in the last 3 to 4 weeks. I think it has improved 100%.” A visitor said, “I have seen the home improving and they are getting there.”

Accident, incidents, complaints or other significant events were logged on an electronic system. The system automatically produced output relating to trends and patterns to support managers to take appropriate actions and to share lessons learned. However, there was little evidence that actions had been taken in response to analysing the trends and patterns. For example, we saw that most incidents of anxieties and distressed behaviours occurred during the afternoon and evenings, but we did not see any specific actions put in place to address this, for example, additional staffing at these times in the day. Following a medicine error, one of the suggestions to prevent reoccurrence was to put photographs on the medicine boxes in the trolleys, and although this had been signed off as completed on the continuous action plan, during our inspection there were no photographs on the boxes.