Madelayne Court

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 remained good.

This meant people were safe and protected from avoidable harm.

This service scored 72 (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 culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider had reporting processes in place for accidents and incidents, and the provider completed statutory notifications in line with their legal requirements and regulation. Staff received regular supervisions and yearly appraisals. The provider shared lessons learned with the wider team to ensure continuous learning around accidents and incidents. They also carried out lessons learned processes around concerns and complaints to help drive improvement. Staff we spoke to had a good understanding of their responsibilities to report accident and incidents and the providers processes for this.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked in partnership with other professionals such as GPs, dietitians and speech and language therapists (SALT) to support people to access healthcare when they needed it. The GP visited the home regularly, and when people moved between services, information was shared to ensure people’s needs could continue to be met safely.
The provider had systems and processes in place for pre assessment of peoples’ needs prior to their admission to Madelayne Court Care Home.
 

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. The provider shared concerns quickly and appropriately.

Whistleblowing and safeguarding policies were in place and were accessible to staff. Statutory notifications were submitted accordingly, and safeguarding’s raised with the local authority. Staff had received training in how to safeguard people from abuse and understood how to report concerns. One staff member told us, “I would report to the manager or deputy manager, and I am aware of whistleblowing.”

Feedback from people and their relatives was mostly positive around feeling safe. Comments we received included, “Yes I feel [relative] is safe because people are around if [relative] needs anything”, and “Yes, I do feel safe here, because I like it, the staff do talk to me if I need anything.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We reviewed care plans and risk assessments during our assessment of Madelayne Court Care Home. Risk assessments were mostly well detailed, but we did identify some areas where information was more generic. Risk assessments were being reviewed regularly and feedback we received was mostly positive around people and their relatives being involved in the reviews. Comments included, “I am phoned regularly about [relatives] care and what actions are being taken including any medical issues”, and “We do feel we can ask questions, and see [relatives] care plan, for example when we visit.” However, 1 relative told us, “I get told the care plan is being updated but I don’t see the changes.”

Staff told us they felt they had sufficient information to support people safely and staff we spoke with had good knowledge of people’s needs and how to maintain people’s safety.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Necessary safety certificates were in place to support safe environments in areas including gas safety, legionella and electricity checks. We found wardrobes were secured to the walls and necessary window restrictors were in place. Checks relating to fire safety were up to date for example, emergency lighting and fire doors. Personal Emergency Evacuation Procedures (PEEP’s) were in place to guide staff with how to support people to evacuate the building in the event of an emergency.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We received mixed feedback around staffing levels at Madelayne Court Care Home. Some people told us they had to wait for extended periods of time for support. One relative told us, “I know [relative] is left sitting on the toilet because of being short staffed, so yes, I do feel they need more staff here.” Another relative told us, “They do try to have a member of staff in each main area, lounge or dining room as applicable, but if staff are required to support another member of staff in a bathroom or residents’ bedroom, then these areas can be left without a carer in attendance and this elevates risk of falling or care needs not being met in a timely way.” One person told us, “Yes, sometimes the call bell is answered quick but other times you have to wait.” However, another person told us, “I had to press my bell one day and they did answer it quickly.” During our onsite inspection, we did observe that at times people were waiting a while before staff were able to assist them. For example, while assisting people to the dining rooms, some people were then left for a period of time waiting for their lunch. We observed staff at times, appeared task focused and did not always have the time to interact with people in a meaningful way. Despite concerns around waiting times there was no information that demonstrated people had come to harm. We fed this back to the provider on the day of the inspection, and the provider was receptive to our feedback.

Staff had received the appropriate training and had regular supervisions. Staff we spoke with told us they felt the induction and training had been good. One staff member told us, “The induction was really good. I was a new carer. It was good quality training. It’s online and practical.”

The provider had recruitment procedures in place to ensure the required checks were carried out prior to staff commencing their employment. This included enhanced Disclosure and Barring Service (DBS) checks for adults. DBS checks provide information including details about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

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.

The home was clean and tidy with no malodours. The home was free from clutter and walkways were not obstructed. We observed domestic staff during our on-site inspection and staff had received the appropriate infection prevention and control (IPC) training and the provider also had an IPC Champion. Staff were observed practicing good IPC during our onsite visit, including wearing appropriate personal protective equipment (PPE).

The provider had an up-to-date policy and procedures in place for IPC, and regular audits were completed. During our onsite observations we did identify a bath that needed cleaning and 1 of the under-sink cupboards in 1 of the kitchenettes required cleaning. We addressed this with the provider during our onsite visit and they resolved this immediately.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

The provider had the appropriate processes in place to ensure safe administration of medication. We observed safe practice during medication administration. People received their prescribed medicines in accordance with their needs. Medication was stored appropriately. The clinical room was clean, tidy and daily temperature recordings were completed.

We reviewed PRN – ‘as required’ protocols and found these contained the required information and were being reviewed regularly. Staff had received the appropriate training, including competencies being reviewed, to safely support people to receive their medicines.