Madeira House

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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to not having suitably skilled numbers of staff available to provide person centred care.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive approach to safety, based on openness and honesty. However, staff did not always understand why or how to apply lessons learnt to their practice and the previous registered manager had not always listened to concerns about safety nor ensured they were investigated and reported appropriately. However, lessons had been learnt by the provider to reduce the risk of safety events not being acted upon appropriately and to improve the learning culture at the service. People and relatives were unclear on outcomes of investigations following incidents or complaints being raised but were confident the new manager and the staff team managed them well. One person told us, “We are lucky with the new manager as they are experienced and want to change things for the better, I hope they are here for good.” A relative said, “My [family member] has had a couple of falls whilst in the home. The staff called to inform me of these 2 incidents. Don’t know if they investigated the 2 falls to prevent it happening again.” Professionals we spoke with were aware of the current improvements taking place. One professional told us, “In a full review at Madeira house I had concerns about several areas. An improvement plan was put in place. Progress/action has been started in all areas but we all felt [more time] would be needed for some of the actions.”

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. People gave consent to any restrictions that helped keep them safe such as support with medicines or going outside. For people who were unable to make these decisions for themselves, staff ensured mental capacity assessments were completed and they applied for a Deprivation of Liberty Safeguard (DoLS) to ensure any restrictions were in the person’s best interest and lawful. The provider shared concerns quickly and appropriately. People told us they felt safe and were happy with the support received. One person told us, “The staff visit regularly as I do get wobbly, so it is reassuring that they keep a check on me.” A relative said, “I have seen my [family member] go from a frail person to the well cared for, healthier, happier person they are now. This is good care.” Staff understood how to recognise, and report concerns of harm or abuse. One staff member said, “I would report to the new manager, unless it is the manager suspected of the abuse then it would be head office. You can do a complaint to CQC or call the police or the safeguarding team.”

The provider did not always support people to understand and manage risks. People told us they were not involved in reviews of their care including risks but were happy staff supported them safely. One person told us, “I do try and get up and about, but they insist I have a staff member with me as I am prone to falling.” A relative said, “I wasn’t involved in discussions about my [family member’s] care and support and I haven’t had the opportunity to raise any issues with staff.” Relatives told us they were concerned about their family member’s having accidents following poor moving and handling support. A relative said, “There has never been any discussions to manage my [family member’s] risks. They use equipment, which they can’t use alone. They need a member of staff to be behind them, so if short staffed which they are always, my [family member] can’t move from their room.” The provider had since ensured all staff had been refreshed on the correct moving and handling techniques and this was monitored regularly. Staff provided care to meet people’s needs that was safe, but care records showed inconsistent or missing information that placed people at risk of avoidable harm if staff did not always have access to the correct guidance. The provider recognised this and was in the process of ensuring a full review of all care records and told us they would be inviting people and those important to them, to participate in those reviews.

The provider identified and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. However, there were multiple areas requiring decoration and the environment was not always designed with the needs of people living with dementia or other cognitive impairments in mind. There was limited evidence of how the environment was designed to support people to find their way around the service and reduce the risk of falls. The provider already had a refurbishment plan underway and had put a new rolling maintenance programme into place. Work on the re-decoration had already begun and they had purchased more dementia friendly signage and were reviewing other ways of improving the environment for the benefit of people living at the service. For example, they were creating a cinema room, a sensory room and a library to enable people the opportunity to utilise spaces in ways they preferred.

The provider was in the process of recruiting a new manager, new deputy manager and support staff. They had ensured agency staff were in place to cover any shortfalls in numbers. However, this meant there was not always enough qualified, skilled and experienced staff at the time they were needed. Until the recent changes in management, staff had not received effective support, supervision and development. One staff member said, “We don't get any kind of supervision or appraisal, I just do the best I can, but they never tell me if I have done anything good or give feedback.” Staff worked together to provide safe care, but they were not always able to meet people’s individual needs, particularly during busy times such as mornings and mealtimes. People and staff told us this resulted in rushing people and long wait times for support. One person told us, “I know they look after me and they are kind, but they need more staff as I have to wait for a carer sometimes, especially at night.” Another person said, “Sometimes I am left in bed longer than I care to be, but I know staff numbers are low.” Relatives were concerned about physical and emotional needs not always being met due to staffing shortages and agency staff who did not know their family member as well. They told us they often found their family member had body odour due to infrequent showering and continence care. A relative said, “There are not enough staff to do the very basic physical tasks let alone offer emotional and social support. I don’t think the staff can perform as well as they should or could.” Another relative told us, “Due to poor staffing levels my [family member] now is holding on to their urine because the staff take such a long time to help them to use the toilet.” The provider was actively recruiting and implementing policy and procedures to ensure staff were fully supported to enable them to better meet people’s needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. People felt the home was kept clean and staff did a good job. A person said, “I believe the home is clean and doesn’t smell. The staff wear gloves when doing personal care tasks. I think the home is well maintained.”

The provider made sure that medicines and treatments were safe and met people’s needs, abilities and preferences. Staff involved people in managing their medicines, including when changes happened. Audits took place regularly and any areas of concern were identified and quickly resolved. Records had been updated and checks showed that stock amounts were correct. People felt their medicines were well managed. One person said, “Medicines are given at regular intervals and if there are changes my [relative] gets a call.” A relative told us, “Medication is given to my [family member] when they need it. I have no concerns, and I do believe pain relief is given when they need it.”