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

We identified a breach of the legal regulations.

Staff did not always assess risks to people's health and safety or mitigate them where identified. Risk assessments were incomplete and did not include risks we identified during our assessment. People did not always have care plans to guide safe practice.

However, the rating for the key question of Safe has improved to Requires Improvement. At the time of our assessment a new manager had been recruited and had been in post for a period of two weeks. Improvements had been made to the process of reporting and managing safeguarding concerns. Staff were now confident to raise any concerns they had with the management team and felt that appropriate action would now be taken. Staff felt there had been changes and improvements made since the last inspection. However, people’s care records including their risk assessments were not always up to date or in place to keep people safe and mitigate risk. Staff told us that the training they received had improved however, the training records were not up to date; we could not be assured that staff had received the appropriate training to meet people’s needs including their specialist needs. Accidents and incidents involving people had not always been assessed and reviewed to prevent a reoccurrence. There were enough staff to meet people’s needs, the manager told us there was a continuing period of recruitment to fill the remaining vacancies. Medicines were managed safely in line with national guidance and supported by organisational policies. People were kept safe by the infection prevention and control processes in place.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us that they felt lessons had been learnt since the last inspection. Staff said that lots of staff were no longer working for the service and there had been a change in the management team.

One staff member said, “I read the report of the last inspection, I think lessons have been learnt. The staff that were there are no longer here. They have improved our training.”

Another said, “What have I Learnt? I have learnt whistleblowing is ok. I would report concerns. I think lessons were learnt. The home is a completely different place. We have daily meetings now with all heads of department. Everyone knows what they are doing and what is expected of them.”

However, some people’s care records including their risk assessments were not always up to date or in place to keep people safe and mitigate risk. Some care records had either been written following the on-site assessment when this had been requested or they had been reviewed by the new manager, some documentation contained the incorrect information including the person’s name and gender. Accidents and incident records involving people had not always been assessed and reviewed to prevent a reoccurrence. The manager had been in post for two weeks. They were aware of the challenges that had been present and were clear there were improvements still needed to be made.

People were positive about their experiences of living at Madeira Lodge. People felt safe to speak with staff or the manager if they had any worries or concerns.

Feedback from relatives was generally positive, one told us, “The care has improved, and I feel my (loved one) is better supported and understood more now, than when they moved in. I think they needed more time to settle but they weren’t being given that opportunity to start with.”

Staff told us they felt people were being admitted to the service more safely than they were before. They also told us; they felt the needs of people currently living at the service could be managed safely.

“Admissions have improved since last time you came. People living here are being supported well. Last time the managers had accepted people who really needed support from a different service. Now the assessments are more robust and management only admit people who we can safely care for.”

However, some people’s care records contained information about external health care professionals they were working with and any action that had been taken, however, this was not consistent. Some care records had either been written following the on-site assessment when this had been requested or they had been reviewed by the new manager, some documentation contained the incorrect information including the person’s name and gender. The new manager said that they and the new assistant manager had experience of supporting people to effectively manage their anxiety and distress.

Commissioning had not received any negative feedback from colleagues such as social workers/care managers. A recent visit took place from a new commissioner who did not raise any concerns after hearing the plans the new manager had in place.

Accidents and incidents had not been managed well. There had been a high number of incidents in relation to people’s anxiety and distress, resulting in aggression towards staff and/or other people living in the service, and damage to the environment and property.

Staff were required to complete an incident form to record the details of the incident, what the triggers were or the circumstances leading up to the incident, and what action was taken following the incident. The incident record included space for follow up and management notes and sign off. Many incident forms had not been fully completed and had not been followed up or signed off by a manager.

There had been no management oversight of accidents and incidents. A monitoring process was not in place to analyse accidents and incidents either for individuals or across the service. This meant themes, trends and learning from events that put people at risk of harm were not used to inform the assessment of risk and the practices within the service.

Some people’s care records contained information about external health care professionals they were working with and any action that had been taken, however, this was not consistent. Referrals to external health care professionals had been sent for some people however, this was inconsistent.

People were supported by staff who knew them well. Staff spoke quietly and respectfully to people. The atmosphere was calm, and people were relaxed.

People and their relatives told us they felt safe at Madeira Lodge. We were told by relatives, “I have no concerns about safety” and “I believe she is safe; she is settled and content.”

One person told us, “I have no complaints but if I did, I’d go straight to the manager.”

Staff were able to tell us what the different types of abuse were, how to recognise them and what they would do to report and raise to their management.

Staff felt confident to speak up and that action would be taken.

A review of records showed that potential safeguarding concerns had been raised with the local safeguarding team and other healthcare professionals as appropriate. There was one current insight alert recorded on our system relating to an increase of safeguarding alerts that have been raised over the past 12 months. A review of records over the past 12 months showed an increase in incidents of physical abuse and aggression between people using the service. There had been no management oversight of accidents and incidents. A monitoring process was not in place to analyse accidents and incidents either for individuals or across the service. This meant themes, trends and learning from events that put people at risk of harm were not used to inform the assessment of risk and the practices within the service.

A training matrix was in place which showed a range of courses available for staff to complete both care staff and ancillary staff. The training matrix showed that staff had received training regarding safeguarding adults.

Staff told us that all risk assessments are kept on the electronic care planning system. Staff said the care records were up to date but they didn't always look at them as they hand important information over to each other, at staff handover meetings. Staff said they got to know people’s risks, likes and dislikes by sharing this information and by spending time with people. One staff member told us that when a new person moved into the service, staff spent time learning about that person including their likes and dislikes.

The manager told us they were aware that some of the care plans and risk assessments lacked detail and were not up to the standard they would expect and were currently working through reviewing and updating them.

Staff knew people well. They knew about specific risks to people for example, one staff member told us, “It is really important to get someone’s diet right when they have diabetes, and to give them their insulin on time. If they became unwell, I would go straight to the senior to get their blood sugar levels checked.”

We saw staff encouraging people to maintain their independence and to make their own choices throughout the day. For example, one staff member told us, “When someone needs personal care, I try to encourage them to do what they can for themselves and say, please lift your arms for me. I’ll help you if you need me to, but I know you’re good at it.”

Not all risks individual risks had been assessed in a timely manner. For example, a pain care plan, diabetes and others had been created on the day the inspector asked for copies. Risk assessment tools were used to identify the level of risk present. However, it was not clear what action was taken when the calculated scores identified a risk. People identified as high risk of, for example, deteriorating skin integrity, or malnourishment did not always have an individual risk assessment to make sure people and staff understood the risks and took consistent preventative action.

Risk assessment documentation contained inconsistencies in the accuracy of information. For example, risks to a person choking had been identified and the documentation stated a choking risk assessment was in place. However, this was not present in the evidence provided.

Another person’s care plan for a catheter mentions that the catheter could cause potential risks to the person’s skin, however there was no mention of this in the risk assessment regarding their skin. There was a risk that the person could pull out the catheter. There was no guidance or information on what staff should do if this were to happen.

Some people experienced serious agitation and distress at times. Individual risk assessments did not sufficiently provide robust guidance for staff to be able to keep people and staff safe.

Staff told us they felt the environment was safe. The provider and manager explained that there were ongoing works to improve the environment for example, replacing some bedroom doors and put in new flooring and bathrooms. However, this work had not yet been completed nor had dates of the potential completion been recorded.

Potential risks to the environment were assessed for example, accessing the garden, keypads on the doors, the use of an electric profiling bed and kitchen equipment. The activity was recorded, followed by the potential risk, hazards or concerns followed by any interventions to reduce the risk and the risk level had then been re-assessed following the interventions that were implemented.

People and their relatives told us they felt there were enough staff. Including feedback such as, “I think there are enough staff, they talk to residents” and, “You see enough staff, always two or three in each lounge.”

The manager told us that there were still vacancies however six new members of staff had been recruited since they had started. There was currently no activity co-ordinator, so staff were completing this role during the day. The service did not have a 'cook' in post however, a kitchen assistant was ‘acting up’ and was said to be managing well. A new member of housekeeping was recruited the day before our site visit meaning the service has full complement of housekeeping staff.

The manager told us that there would be face to face Positive Behaviour Support (PBS) training implemented soon, no date given but this would be to assist staff and help them to support anyone who presented as agitated or anxious.

There were enough staff on shift during our site visit to meet people’s needs. People’s feedback and observations supported this with no concerns with staffing currently.

Systems were in place to ensure there was enough staff on duty to meet people’s needs. However, the manager told us they were continuing to recruit to fill the current vacancies.

The current compliance rate showed a score of 96% from the training matrix that was emailed over to the assessor. However, we could not be assured that staff had received the appropriate training to meet people’s assessed needs including their specialist needs.

Staff were able to describe the actions needed to minimise the risk of infection to people at the service. They continued with best practice when it came to washing their hands and changing their personal protective equipment (PPE) between different tasks. Staff were wearing appropriate PPE and told us there was adequate supply whenever they were needed. The service was clean and we found no concerns in relation to the management of infection control.

Feedback from staff was that staff had to be medicines trained to administer medicines. According to the training matrix this meant only two members of staff had completed the training and were therefore able to give medicines to people in the service. This meant that people could have been at risk of not receiving their medicines if the trained staff weren't there. However, following the on-site assessment the manager emailed through medication competencies for eight members of staff which was different to the information within the training matrix.

Medicines were managed safely in line with national guidance and supported by organisational policies. Medicines were stored securely in clean, temperature-controlled conditions.



The provider used an electronic system for documenting people’s administration records. This supported accurate administration as the system kept a running tally of medicines that should be in stock so staff could check accurately with ease.

Medicine administration records were completed accurately. Where people had medicines ‘as required’ (PRN), for example for pain relief, protocols were in place to make sure people received these safely and within pharmaceutical guidelines.

Medicines were audited monthly.

One person had an accident where they fell over. On completion of the accident record, staff recorded they had found ‘a lot of medicines’ in their handbag. On reviewing the accident record, a manager had documented that as a result staff must remove the person’s handbag when administering their medicines. The person’s care plan and risk assessment in relation their medicines, had not been updated with these new risks and the action required to prevent a reoccurence. For example, staff were not guided to be more vigilant in ensuring the person swallowed their medicines before moving away from the person, rather than removing their handbag as per best practice and the provider’s policy when administering medicines.