You are here

Madeira Lodge Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 5 July 2019

About the service:

Madeira Lodge is a residential care home that provides personal care and support for up to 28 older people, some of whom have dementia. At the time of our inspection there were 23 people living there.

People’s experience of using this service:

People told us they felt safe at Madeira Lodge. Relatives we spoke with felt staff knew people well and understood their support needs.

Potential risks to people’s health and welfare had been assessed, there was guidance for staff to reduce risks and keep people as safe as possible. However, some environmental checks and audits had not been fully effective. This was because some planned safety checks had lapsed and other checks had not resulted in risk being reduced. Additionally, fluid monitoring measures, intended to support people to drink enough were not sufficiently developed to support people effectively. Management oversight of the service had not identified or addressed these concerns and was not therefore effective.

We observed people being treated with kindness and compassion. People were supported to be as independent as possible.

Medicines were stored, managed and administered safely; improvements suggested during the inspection were put in place immediately.

People’s needs were assessed and used to develop a care plan. These were reviewed regularly and, where possible, people agreed their care plan and they and their relatives were involved in reviews.

Accidents and incidents were recorded, investigated and action taken to reduce risk. Risk assessments were reviewed and updated to ensure they were effective.

People told us there were enough staff to support them as they preferred. Staff had been recruited safely and they received appropriate training and supervision.

Staff and the registered manager understood their responsibility to protect people from abuse. Staff spoken with could explain how any suspected abuse would be reported.

People were encouraged to make decisions about their care and how they spent their time. They received access to healthcare professionals and were supported to be as active as possible.

People knew how to complain and were comfortable to raise any issues with the registered manager.

Rating at last inspection:

The service was rated Requires Improvement at the last inspection on 07 February 2018 (Report published 20 April 2018). This service has been rated Requires Improvement at the last two inspections. This is the third consecutive time the service has been rated as Requires Improvement.

Why we inspected:

This was a planned inspection based on the rating at the last inspection.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at

Inspection areas


Requires improvement

Updated 5 July 2019

The service was not always safe

Details are in our Safe findings below.



Updated 5 July 2019

The service was effective

Details are in our Effective findings below.



Updated 5 July 2019

The service was not always caring.

Details are in our Caring findings below.



Updated 5 July 2019

The service was responsive

Details are in our Responsive findings below.


Requires improvement

Updated 5 July 2019

The service was not always well-led.

Details are in our Well-Led findings below.