Madelayne Court

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Feedback we received was positive around the management team at Madelayne Court Care Home. People, their relatives and staff told us they felt able to raise concerns and management were approachable. Comments included, “We do feel we can raise concerns regarding [relatives] care and indeed have spoken to staff to question things [relative] has mentioned to us which we felt were investigated and explained to us fully.” And “When I have had an issue, the complaint has been received and dealt with immediately.”

The management and staff we spoke with were positive about the care they provided to people at Madelayne Court Care Home.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

We received positive feedback about the management of the service from staff. Comments from staff included, “Yes management are approachable, supportive and willing to listen any concerns.” During our onsite inspection, we observed the manager knew people well and feedback we received supported this. Professionals also told us they felt management were approachable. One professional told us, “The management is approachable, always friendly and interested in the treatment we provide.”

People and their relatives also told us management were approachable. One relative told us, “Although I have not needed to raise formal complaints, I have raised various queries with Care Team Leaders, the manager and other senior staff members and they are all approachable and helpful.”

The management team were responsive, open and honest throughout the assessment and responded positively to feedback given.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff had received training in safeguarding and whistleblowing and were encouraged to speak up if they had any concerns. The provider had a complaints policy in place and staff were aware of how to raise any concerns. Staff told us they felt comfortable speaking to management.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had a policy in place for equality, diversity and inclusion and staff had access to equality and diversity training. We did not receive any negative feedback from staff around being treated unfairly at work.

We observed a positive culture during our onsite inspection.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had a clear governance framework in place to ensure regular checks of quality and safety were made. Audits were in place to monitor quality assurance and identify areas for improvement, for example around areas relating to health and safety. However, we did identify the issues around waiting times and the lack of choice around modified diet options, which had not been identified via the providers own systems. This was fedback to the provider on the day of the inspection and they were proactive in implementing their own action plan to address this. The provider had audits in place to monitor aspects of the service such as call bell audits and staff were in receipt of regular supervisions. People’s care plans and risk assessments were being reviewed and updated via the resident of the day system and when required.

Statutory notifications were being completed as required and lessons learned processes were in place.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked collaboratively with external healthcare professionals and people were supported to attend appointments when needed. Professionals visited the home regularly to meet people’s needs. The provider facilitated community access for people where possible via the home’s minibus. External services attended the home, for example the Dementia Choir attended every Wednesday.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The provider had audits and governance systems in place, that supported the identification of any areas where improvements were needed. The provider had designated champions of key areas of quality, such as dementia, continence and falls champions.

Management were open to the feedback we gave throughout the assessment and took a proactive approach to make improvements from the feedback we shared.