Archived: Madeira Lodge Care Home

Updated 24 January 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by two inspectors on 14 and 20 October 2022 and three inspectors on the 21 October 2022.

Service and service type

Madeira Lodge is a ‘care home.’ People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Madeira Lodge is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, including their safeguarding team, and professionals who work with the service. We used all this information to plan our inspection. The provider did complete the required Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make.

During the inspection

We spoke with four people who used the service about their experience of the care provided. We observed the care provided within the communal areas where we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with nine members of staff including the provider, registered manager, operational director, deputy manager, kitchen staff and care workers. We reviewed a range of records. This included nine people's care records and multiple medication records. We looked at four staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 24 January 2023

About the service

Madeira Lodge Care Home is registered to provide personal care and accommodation for 48 older people, people who live with dementia and people who need support to maintain their mental health. At this inspection there were 48 people living in the service.

People’s experience of using this service and what we found

People were not protected from harm. We found people had been locked in their bedrooms during the night without their consent and without appropriate legal authorisation. . People did not have full, detailed risk assessments and care plans to enable staff to care for people appropriately. Staff did not follow safe practices when supporting people who needed help to move.

There were significant concerns with the records completed at Madeira Lodge Care home. Care plans lacked detail and had not been regularly reviewed. Some were held on paper records, others on the electronic care planning system, some held on both but did not show the same information. Audits and checks had been completed but were not effective in identifying issues.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Mental capacity assessments were not completed properly and were not individual to the person being assessed to make the decision.

We had significant concerns regarding the culture of the service. Concerns had not been raised by staff to the management team about poor practice in the service. The registered manager told us they noticed a change in the atmosphere amongst the staff since actions were taken following our unannounced visit but did not recognise the wider culture of poor practice in the service.

Staff were not deployed effectively to meet people’s needs. There were many people who were independently mobile and living with advanced dementia who walked around the service without support or interaction from staff. Staffing numbers were determined by the providers dependency tool, which calculated the numbers of staff required to safely meet people's needs. However, this was not reliable or accurate as people’s needs had not been reviewed regularly to determine if the dependency was still relevant.

Accidents and incidents were recorded, but records lacked details of what action was taken, by who or what was needed to reduce the risk of reoccurrence.

Staff did not have the skills or experience to meet the needs of people who were living with advanced dementia.

The dining experience we observed was not positive. Although people were given a choice of food, there was a lack of staff input to make this a pleasurable experience.

People were not always supported to access healthcare in a timely way. Although we found records of people having follow up review appointments with professionals involved in their care, instructions from professionals were not always followed.

Staff did not always treat people in a caring, personal and dignified way. Language used by staff was not kind and interactions we observed did not always treat people well. Staff appeared to lack skills to manage situations where people were becoming distressed or anxious. There was a lack of resources to ensure all people had the chance to engage in activities to help them interact and socialise. There was one wellbeing coordinator responsible for activities for all people in Madeira Lodge Care Home. People did not always have their social needs met.

Staff were recruited safely and demonstrated good infection prevention and control practice.

The layout of the service was large and spacious and there were a number of communal areas for people to choose to spend their time.

The provider and registered manager had a system in place to appropriately record and investigate complaints which had been raised. The registered manager understood their regulatory requirements to inform the Care Quality Commission (CQC) of significant things which had happened at the service and had completed this.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 04 June 2021)

Why we inspected

We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about safety of people, staffing levels and risk assessment and care planning. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with the safety of people using the service, governance, mental capacity assessments, DoLS and care plans so we widened the scope of the inspection to become a comprehensive inspection which included the key questions of safe, effective, caring, responsive and well-led.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to people’s safety, abuse, person centred care, safeguarding, mental capacity, record keeping, effective checks, audits and staffing at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The provider applied to remove this location from their registration in order to register it under a new company. This was completed following this inspection. We will use the findings from this inspection to inform the regulation of the new provider for Madeira Lodge