CQC report explained · a nursing home
What the CQC found at St Margarets
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- Some clinical equipment was not included in formal safety checks. Inspectors also found weaknesses in visitor screening, infection control arrangements and covering short-notice staff absences.
- Effective?
- Good
- People's needs were assessed and care plans guided staff. Consent arrangements had improved, and staff worked with health professionals to meet people's needs.
- Caring?
- Good
- This question was not assessed during the focused inspection. The rating from the previous comprehensive inspection was used in the overall rating.
- Responsive?
- Good
- This question was not assessed during the focused inspection. The rating from the previous comprehensive inspection was used in the overall rating.
- Well-led?
- Good
- Quality checks had become more effective and managers promoted a friendly, person-centred culture. Some further work was needed on archiving, equipment checks and learning from incidents.
What inspectors found, December 2020
St Margarets rated Good overall; inspectors found effective, caring leadership but safety needed improvement.
This was an announced, focused inspection on 29 October 2020. Inspectors spoke with six people, nine staff members and two care workers by telephone. They reviewed care, medicines, recruitment, training and management records.
The overall rating was Good. Effective and well-led were rated Good. Safe was rated Requires Improvement because checks on some clinical equipment were incomplete, infection control arrangements were not fully in line with guidance, and short-notice staff absences were difficult to cover.
The home had improved from Requires Improvement at the previous inspection in July 2019. Consent arrangements had improved and the previous breach of Regulation 11 was no longer in place. This inspection did not assess caring or responsive, so those ratings were carried forward from the earlier comprehensive inspection.
Improved consent practice
Staff had better training and understanding of consent. Best-interest decisions and least restrictive options were recorded when people could not make particular decisions themselves.
“At this inspection enough improvement had been made and the provider was no longer in breach of regulation 11.” from the report
Kind and person-centred culture
Inspectors found the home friendly and welcoming. People and relatives praised the individualised care and staff approach.
“The registered manager and staff promoted a friendly, homely and caring culture where people experienced appropriate outcomes.” from the report
Medicines and safeguarding
Medicines were stored, given and disposed of safely, and staff had training and competency checks. Safeguarding procedures were in place and staff knew how to report abuse.
“Medicines were received, stored, administered and disposed of safely.” from the report
Food and healthcare
People had meal choices, snacks and nutritional monitoring. Health needs were referred to professionals and staff worked with outside agencies.
“People's healthcare needs were met in a timely way.” from the report
Clinical equipment checks
seriousFormal checks did not cover all clinical equipment. The provider was asked to review its systems so equipment was safe to use.
“Not all equipment was included in the formal checks.” from the report
Infection control arrangements
needs fixingInspectors were only somewhat assured about visitor screening and some hygiene arrangements. The manager later confirmed that visitor screening had started and potentially unsuitable furnishings and decorations had been removed.
“We recommend the provider reviews the current government guidance in relation to Covid-19 to ensure it is in place and fully implemented.” from the report
Staffing pressure
needs fixingThere were shortages on the morning of the inspection because of short-notice absence. Staff numbers were generally enough, but recruitment was difficult and agency staff were being used.
“Although there were shortages of care workers on the morning shift of the inspection, due to short notice absence, staff generally felt staffing numbers were sufficient to meet people's needs in a timely way.” from the report
- 01How are you now checking every piece of clinical equipment, and how often are those checks recorded?
- 02How do you screen visitors and keep infection control arrangements in line with current guidance?
- 03How do you cover short-notice staff absences, and how often are agency staff used?
- 04What has been done to prevent delays with lunch and support in the main dining room?
- 05How are you making sure lessons from accidents and incidents are recorded and acted on?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not assessed and their previous ratings were carried forward. This explanation was written from the published report of 3 December 2020 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, July 2019
St Margarets is rated Requires Improvement; inspectors found safe, kind and responsive care, but consent records and management oversight were not reliable enough.
The inspection took place over 10 and 13 June 2019. It was unannounced on the first day. Inspectors spoke with people, relatives and staff, and reviewed care records, medicines records, recruitment files and management records.
The home was rated Good for Safe, Caring and Responsive. Inspectors found enough staff, safe medicines processes, kind and respectful care, and support that responded to people's changing needs. Activities, communication support and complaints handling were also described positively.
The home was rated Requires Improvement for Effective and Well-led. Mental capacity assessments and best-interest decisions were not always recorded properly, including for restrictions such as bedrails, lap straps and medication. Care plans did not always clearly describe people's current needs. The home remained Requires Improvement, the same overall rating as at the previous inspection.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and safe systems for recruitment, medicines and incident learning.
“People received care in a timely way; there were enough staff available to meet people's needs.” from the report
Kind and respectful care
Staff knew people well and supported them with patience, dignity, choice and independence.
“People were cared for and supported by staff that were kind, patient and respectful.” from the report
Responsive support
The home provided activities, supported relationships and adapted care when people's needs changed. Complaints were handled appropriately.
“Staff provided responsive care, adapting this as people's needs changed.” from the report
Health and nutrition support
People received support with healthcare, balanced meals, drinks, snacks and special diets. Staff worked with healthcare professionals when needed.
“People received a healthy, balanced diet which met their needs and took into consideration their preferences and any special dietary needs.” from the report
Consent and mental capacity records
seriousThe home did not consistently record whether people had capacity to make decisions or why restrictions were in their best interests and the least restrictive option. This was a continued breach of Regulation 11 and placed people at risk of harm, although inspectors found no evidence that anyone had been harmed.
“People's capacity to make these decisions was not always completed or recorded why the restrictions were in their best interest and the least restrictive option.” from the report
Care plans were not consistently complete
needs fixingCare plans had been updated but did not always describe people's current needs clearly enough for staff. Inspectors recommended that accurate and complete records be maintained as needs change.
“There were inconsistencies in the information recorded, some care plans were detailed, others had little information and some information was missing.” from the report
- 01How do you now record mental capacity assessments and best-interest decisions for bedrails, lap straps and medication?
- 02How do you check that any restriction is legally authorised and the least restrictive option?
- 03What has changed in your care plan audits since this inspection, and how do you make sure plans reflect current needs?
- 04How will you show families that the Regulation 11 breach has been fully addressed?
- 05When will the next CQC reinspection or progress review take place?
This inspection looked at the home, the care provided and all five CQC questions; Safe, Caring and Responsive were rated Good, while Effective and Well-led were rated Requires Improvement. This explanation was written from the published report of 27 July 2019 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 St Margarets
4 rated inspections over 5 years: the service has held its Good rating throughout.
- December 2020Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2019Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- June 2018Requires improvementdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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12 live-in carers within about an hour of North East Lincolnshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,350 a week. 10 can care for a couple. 7 years' experience on average.
“What truly stands out is how mindful and attentive she is to all of my medical needs, always going above and beyond to ensure I’m comfortable and well cared for.”
“Martin was more than a carer, he managed the home and became my uncle's best friend, enriching his life during his last few years.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.