Madeira House

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 Requires Improvement. At this assessment the rating has changed to Good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care. At our last assessment, we found the service was in breach of legal regulations in relation to good governance. At this assessment we found enough improvement had been made and the provider was no longer in breach.

This service scored 71 (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. The registered manager had worked hard at improving the culture of the service since our last assessment. People, their relatives and staff described to us “a before and after” the arrival of the new and current registered manager, highlighting their positive impact on the service. One relative told us, “[Registered manager] is a brilliant manager. It is because of [them] that things have improved. I cannot praise [them] enough.” We found the service atmosphere to be relaxed and welcoming. We observed positive interactions between people and staff, although more engagement during meal service was needed. Staff described a positive culture and told us morale was good. One staff member said, “We work with us as a team.” Another staff member said, “We help each other out when needed.”

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. The registered manager was open and honest throughout the assessment. They responded to requests for information promptly and acted with integrity. Staff described leaders as experienced and effective. People and their relatives spoke positively about leaders at the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. People, their relatives and staff told us they felt comfortable raising concerns and felt these would be acted on. Freedom to speak up was supported by the providers policy and procedures.

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 diverse workforce and treated staff equally and fairly. Staff told us they worked well as a team and enjoyed working at the service with people. One staff member said, “Everyone is like a big family and treated with respect. Genuine kindness. They ask if I can help and I do. Another staff member said, “All staff are caring, and we are family.”

The provider mostly had clear responsibilities, roles, systems of accountability and good governance. However, these were not always used effectively to ensure quality of service in all areas. The provider acted on information about risk, performance and outcomes, and shared this securely with others when appropriate.

Staff had clear responsibilities and there was a good range of roles in place to support service delivery. Effective oversight processes were in place. For example, monitoring tools were used to ensure the timely completion of staff training, competency assessments and deprivation of liberty applications. A monthly quality metrics spreadsheet was used to record and analyse service delivery. This included complaints, medicine errors, wounds, falls, safeguarding, infections, safety incidents, mortality, people’s weight monitoring, trends and dependency. A range of quality assurance processes were in place that were mostly effective. However, they were not always used effectively, as shortfalls with people’s care plans, risk assessments, and kitchen cleanliness, were not always identified.

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. Leaders and staff collaborated with people and relatives to ensure people received the care they needed. Referrals to health care professionals were made when required and visits to the service were facilitated.

The provider and registered manager 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. The registered manager was passionate about the service, people and the staff. They demonstrated genuine compassion for others and supported the service to develop a positive learning culture. As a result of their efforts, we found the service was on a development journey and significant improvements had been made since our last assessment. The providers internal oversight mechanisms supported the development of the service. The registered manager told us they felt well supported by the provider. Whilst there were a few shortfalls identified as part of this assessment, we were assured by the registered managers responsiveness and prompt action taken.