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

We identified two breaches of the legal regulations.

There was not always a consistent culture of continuous learning and improvement. The systems that were in place failed to identify the concerns that were found on site during this assessment. There was a lack of governance, management and oversight of the service. People did not always have care plans or risk assessments to guide safe practice.

However, the rating for the key question of Well-led has improved to Requires Improvement. Improvements had been made to the management support and guidance the staff had received. Staff told us they felt that positive changes had been made since the last inspection and they felt confident the new manager would continue to make positive changes. At the time of our assessment a new manager had been recruited and had been in post for a period of two weeks. The new manager had ideas and systems that she had planned to implement, such as the governance systems were being improved and implemented but weren't fully embedded. The current monitoring and auditing processes that were in place were not always effective and had not identified the concerns that were found during this assessment. Some people’s care plans and risk assessments had all been reviewed and, in some instances, created on the day inspectors asked for them and the manager told us that all care plans were in the process of being reviewed.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We discussed with staff whether they felt there had been an improvement at the service since the last inspection and the feedback was wholly positive.

One member of staff said, "The service has definitely improved since you were here last. It was clear that the things going on were terrible. We are now able to raise things and if we are concerned, we know action will be taken. That’s a better culture, I think. I think we have a good team and there has been an improvement since the old staff have left."

Staff we spoke with were asked if they would recommend the service if their own loved ones needed support.

One member of staff said, "If my family needed care I would recommend. I love it here there’s nothing horrible. The residents have kept me here! It’s like a family. "

A continuous improvement and development plan was in place and created in November 2023 with actions for the previous registered manager and new actions for the current manager. The new manager had started to implement changes to improve the service including reviewing, updating and implementing people’s care records.

Feedback on the new manager was generally positive. Most staff were unable to feedback fully as the manager had only been in post a few weeks. However, when they did give feedback, it was positive, and they understood what plans were in place.

One member of staff said, "The manager, they are doing well. They have an open-door policy. If it is shut, it’s for a reason. You can go into talk to them. The manager has also said we can have more training. I find them fair and treats everyone well. "

Another said, “The provider I have seen them in the home a few times, there haven't been any meetings with them that I'm aware of. However, If I had an issue, I would be able to speak to them.”

The new manager stated they felt very supported by the provider and area manager although there is confusion as to what the area managers accurate role was.

Staff told us they would be confident to speak up if they needed to and felt that issues found at the last inspection had been learnt.

Although some staff felt they had not got to know the new manager in the few weeks they had been in post they were clear in who else they could go to in the event of raising concerns or issues.

Some feedback from staff included, "I would be able to speak up. I would not have a problem with that at all. I would go to who I needed to. I have no concerns that people would speak up if they needed to."

"I have had to raise a concern recently and it was investigated and dealt with. I am confident new manager would do something, they are very supportive."

Staff told us there were no concerns with the diversity of the workforce. We saw recruitment records of staff being recruited from overseas. Staff employed were from different cultures, different ages, different genders and had been recruited safely.

The new manager told us that governance systems were being improved and implemented but weren't fully embedded.

Care plans and risk assessments we requested had all been reviewed and, in some instances, created on the day inspectors asked for them and the manager told us that all care plans were in the process of being reviewed and updated as per their standards.

Systems were in place to monitor the quality of the service people received; however, these were not completed on a consistent basis. For example, the provider monthly visit form was completed in October 2023 followed by January 2024. This had been completed by the care consultant appointed by the provider. An identified concern in October 2023 regarding the odour of a person’s bedroom had not been followed up in the January 2024 visit, nor had it been recorded what action had been taken to address the odour. Other monthly audits completed by the management team had not been completed consistently nor had they identified the concerns that were found during this assessment.

The provider and manager described their relationship with the Local Authority Social Services teams as well as the NHS commissioners positively. They received referrals and then completed an initial assessment to determine if they could support the person requiring a placement.

The manager told us that there were lots of changes and improvements being made but had not been fully embedded at time of the assessment. There had been many changes to the management team within the service. Staff fedback that they understood changes were being made and that changes already implemented, such as allowing animals back into the service will have a positive impact on people.

The new manager followed a continuous improvement and development plan was in place and created in November 2023 with actions for the previous registered manager and new actions for the current manager. The new manager had made improvements since starting in their post and had plans for further improvements to the service. Staff felt there had been a number of positive changes since the last inspection and were confident that changes would continue with the new manager.

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 current monitoring and auditing processes that were in place were not always effective and had not identified the concerns that were found during this assessment.