CQC report explained · a residential care home
What the CQC found at Margaret's Rest Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, June 2023
Rated Good; inspectors found clear improvements in safety, care planning and management, with two minor shortfalls addressed during the visit.
This was an unannounced focused inspection on 18 and 19 May 2023. One inspector and an Expert by Experience spoke with people, relatives, staff and a health professional. They reviewed care plans, medicines records, staff files and management records.
The home was rated Good overall and Good for Safe, Effective and Well-led. Inspectors found that risks were assessed, medicines were generally managed safely, staffing was sufficient, care plans had improved and people could access health care. People and relatives said they felt safe and were happy with the care.
There were two shortfalls during the inspection. An opened medicine with a short shelf-life had not been dated, and food and drink monitoring was only checked by night staff. The medicine was removed, a replacement was ordered and monitoring of food and drink was increased immediately.
The previous rating was Requires Improvement, with breaches relating to risk management, medicines and governance. The report says the home had made enough improvements and was no longer in breach. Safe, Effective and Well-led all improved to Good, while Caring and Responsive were not covered by this focused inspection.
Improved risk management
Individual risks were assessed, monitored and reviewed. Staff had detailed guidance about how to keep people safe.
“Risks associated with people's individual needs were assessed, mitigated and monitored well and kept under review.” from the report
Safe medicines support
Medicines were generally given at the right time by trained staff. Records and guidance for medicines given when needed had improved.
“Medicines were administered at the right time by staff trained and assessed competent to do so.” from the report
Personalised care plans
Care plans had been updated and included people's routines, preferences, wishes and individual risks.
“Care plans were updated, contained accurate person-centred information and considered the protected characteristics and other diverse cultural needs.” from the report
Sufficient staffing and training
Inspectors found enough staff to meet people's needs. Recruitment checks, induction and ongoing training were in place.
“There were enough staff to meet the needs of people living at the home.” from the report
Stronger management systems
The new registered manager had introduced regular audits and checks. Problems found through these systems were acted on.
“New and improved systems were in place to monitor the quality and performance in all areas of the service.” from the report
Medicine not dated
minorAn opened medicine with a short shelf-life had not been dated. It had not been given recently, but there was a risk it could have been used; it was removed and replaced during the inspection.
“We found 'as and when required' medicine with a short shelf-life had been opened but was not dated.” from the report
Food and drink monitoring
needs fixingRecords of what people ate and drank were only checked by night staff. This could have delayed action if someone was not eating or drinking enough. The home increased monitoring during the inspection.
“Food and drink consumed by people was documented but only checked by night staff.” from the report
- 01How often are medicines given when needed now checked, including their opening dates and expiry dates?
- 02How is food and drink intake monitored throughout the day, and what happens if someone is not eating or drinking enough?
- 03What changes have been made since the previous inspection, and how are you checking that they continue?
- 04How will you make sure care is adapted to my relative's individual routines, preferences, health needs and risks?
- 05What feedback have you received about the Caring and Responsive aspects of the service, which were not covered in this inspection?
This was an unannounced focused inspection covering Safe, Effective and Well-led, including infection prevention and control; Caring and Responsive were not inspected and their previous ratings do not appear in this report. This explanation was written from the published report of 17 June 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, May 2023
Margaret's Rest Home rated Requires Improvement; inspectors found increased safety risks, poor records and weak oversight, although recruitment, infection control and health support were positive.
This was an unannounced focused inspection on 22 June 2022. Inspectors checked Safe, Effective and Well-led. They spoke with six people, four relatives and eight staff, and reviewed care, medicine, recruitment and management records.
The home did not always record risks, injuries, medicines or care tasks properly. Some care plans contained missing, wrong or conflicting information. Unexplained injuries were not always investigated, and medicine records did not consistently explain why medicines were given.
Inspectors found safe recruitment, infection control and access to health professionals. People and relatives said they could raise concerns, and complaints were dealt with within the provider's time frames.
The overall rating stayed Requires Improvement. Safe and Well-led remained Requires Improvement. Effective fell from Good to Requires Improvement. The report says there had not been enough improvement since the previous inspection, and the home was still breaching regulations.
Safe recruitment
The home checked previous employers' references and completed DBS checks before staff started. New staff also had an induction and shadow shifts.
“People were supported by staff who had been recruited safely.” from the report
Infection control
Inspectors were assured that the home followed guidance on visitors, testing, protective equipment, hygiene and managing infection outbreaks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Access to healthcare
People were referred to health professionals when needed, including falls, speech and language, dietetic and occupational therapy services.
“People were referred to external health professionals as required.” from the report
Open communication
People, relatives and staff said they could raise concerns with the registered manager. Relatives were kept informed about progress and incidents.
“People, staff and relatives felt able to discuss and raise any concerns with the registered manager.” from the report
Unmanaged risks and injuries
seriousSome risks had no assessment or recorded safety measures. Unexplained injuries were not always investigated, and injury records lacked details needed to monitor healing.
“The provider had failed to ensure risks to people's health and safety had been assessed and done all that is practical to mitigate those risks.” from the report
Medicine records
seriousRecords did not consistently state why medicines were given, including why a higher dose was used instead of trying a lower dose first. Thickener amounts were also not recorded.
“People were at risk of not receiving medicines as prescribed.” from the report
Incomplete care records
needs fixingRecords had gaps for oral care, repositioning, continence care and personal hygiene. This meant the provider could not be sure that people's assessed needs had been met.
“This meant the provider could not be assured that people's needs were being met.” from the report
Weak management checks
seriousAudits did not find the problems inspectors identified. One care file was reviewed in depth each month, meaning some files might not have a full review for nearly two years.
“Audits were not effective in identifying incorrect or missing information within care plans and risk assessments.” from the report
Training gaps
needs fixingThe training records did not show that all staff had completed training in communication, oral hygiene, behaviour, and fluids and nutrition. Staff had mixed views about the training.
“The training matrix did not evidence all staff had training in communication, oral hygiene, behaviour and fluids and nutrition.” from the report
- 01How are you now investigating unexplained injuries, and how do you record follow-up checks?
- 02How do you record why PRN medicines are given, why a higher dose is used, and whether it worked?
- 03How often is each person's care plan and risk assessment now reviewed for missing or conflicting information?
- 04How do you check that oral care, repositioning, continence and personal hygiene tasks have been completed?
- 05What training have all staff now completed in communication, oral hygiene, behaviour, and fluids and nutrition?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected, and the overall rating used the previous inspection ratings for the questions not reviewed. This explanation was written from the published report of 17 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Margaret's Rest Home
6 rated inspections over 7 years: the service has held its Good rating throughout.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2023Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- September 2021Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- October 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- May 2018GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- November 2016Inspected but not ratedSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- May 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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