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Madeira Lodge Care Home Requires improvement

We are carrying out a review of quality at Madeira Lodge Care Home. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 21 April 2018

This was an unannounced inspection carried out on 7 February 2018.

Madeira Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Madeira Lodge is registered to accommodate care and support for up to 28 older people. At the time of the inspection there were 25 people living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We last inspected the service on 8 and 9 January 2017, the service was rated as requires improvement. There were three breaches of regulations at this inspection. These were the lack of information written in the care plans which did not always reflect people’s assessed needs and preferences. Risks had been assessed but not always mitigated to keep people as safe as possible and the systems in place to monitor the care being provided were not effective.

At this inspection new personalised care plans had been implemented with additional information; however these had not always been updated to reflect the care being provided. Detailed risk assessments were in place but lacked information about how to manage the risk and what further action should be taken to keep people safe.

Checks and audits were being carried out regularly by the registered manager and staff but these audits had not identified the shortfalls found at this inspection. Therefore, the breaches identified at the last inspection had only been partially met.

The registered manager worked in partnership with other professionals, such as people’s care managers and the mental health team. However they had not informed the local authority safeguarding team of an incident which occurred at the service. We have made a recommendation about consulting the local authority safeguarding protocols.

Medicines were not always managed safely. Accidents and incidents were recorded and analysed by the registered manager. However further analysis was required to show that previous falls and incidents were taken into account to reduce the risk of them happening again.

People’s needs had not always been assessed when they came into the service for a short period of time (known as respite care) and detailed care plans were not in place for these individuals. People were supported to eat and drink, however. records of people’s fluid charts were not clear to confirm that people were receiving enough fluids to keep them hydrated.

People’s preferences of how they wished to be cared for at the end of their life were not consistently recorded. We have made a recommendation about seeking advice and guidance from a reputable source about end of life care planning in line with current guidance.

All staff had completed ‘on line’ training courses, however there was no practical face to face training for topics such as moving and handling, challenging behaviour and first aid, to show the practical element and assess staff competency. There was a lack of detail in the complaint records to confirm what action the provider had taken and whether complaints were resolved in a satisfactory manner.

Checks on the premises had been made to ensure it was safe and the provider had ensured that the environment was suitable for people living with dementia.

The registered manager had not always notified the Care Quality Commission, as required by law of events that happened in the service such as safeguarding and when serious incidents occurred.

Staffing levels were sufficient at the time of the inspection an

Inspection areas


Requires improvement

Updated 21 April 2018

The service was not always safe.

Risks relating to people's care and support had been assessed but there was a lack of information to guide staff about how to keep people safe.

Staff had not consistently reported incidents to the local safeguarding team.

Medicines were not always managed safely.

Accidents and incidents had been recorded but there was not always detailed information to confirm what action had been taken.

There were enough staff to meet people’s needs and they were recruited safely.

Systems were in place to reduce the risks of infection.


Requires improvement

Updated 21 April 2018

The service was not always effective.

People who were receiving respite care at the service had not had their care needs assessed before they were admitted to the service.

Staff had received on line training but there was a lack of face to face practical training to ensure staff had the skills and competencies to complete their role effectively.

Staff had regular supervision and an annual appraisal to discuss their learning and development needs.

Staff ensured that appropriate referrals were made to health professionals for specialist support. People were supported to eat and drink safely.

People were supported to make decisions about their care and support. Applications had been made to the local authority in line with the Deprivation of Liberty Safeguards.

The service was continuing to make changes to the environment to support people living with dementia to help them orientate themselves.



Updated 21 April 2018

The service was caring.

People were treated with kindness and respect. Staff were patient and were attentive when people became anxious.

People were given choices of what they wanted to do or where they wanted to go. Staff listened to people and treated them with dignity and respect.

Staff encouraged people to become more independent by supporting them to do things for themselves.

Staff smiled and chatted with people


Requires improvement

Updated 21 April 2018

The service was not always responsive.

In some cases people’s care plans were detailed with personal information about their care whilst others did not always reflect the care being provided

Records of complaints did not always show what action the provider had taken to resolve complaints.

The provider was currently introducing person centred activities and working with outside agencies to achieve this.

People were observed enjoying the varied activities being provided at the time of the inspection.

The service provided end of life care but was not providing end of life care at the time of the inspection


Requires improvement

Updated 21 April 2018

The service was not consistently well-led.

The provider had worked hard to introduce new systems to ensure the service was compliant however there remained continued breaches of the regulations.

The provider had implemented systems to check the quality of care being provided however the outcome of the audits had not identified the shortfalls found at this inspection.

In some cases, further analysis was required in the accident and reporting system to show clearly what action had been taken to continuously drive improvements.

Staff understood the visions and values of the service, however the service was not always inclusive such as involving people in menu planning, or providing easy read information to support people about how to complain.

The registered manager had not always submitted notifications in line with guidance.

The registered manager worked alongside the staff to monitor the quality of care being provided.