CQC report explained · a residential care home
What the CQC found at St. Margarets Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Inspectors found enough staff, safe medicines management, infection control measures and systems for handling accidents and incidents.
- Effective?
- Good
- Staff had relevant training and support. People’s needs were assessed, their food and drink needs were met, healthcare was available and staff generally worked within the Mental Capacity Act. Consent recording needed improvement.
- Caring?
- Good
- People and relatives said staff were kind, respectful and considerate. People were involved in decisions and supported to maintain their privacy, dignity and independence.
- Responsive?
- Good
- Care plans reflected people’s needs, preferences and personal histories and were regularly reviewed. The home supported communication, relationships, activities and complaints.
- Well-led?
- Requires improvement
- There was a clear management structure and people and relatives were positive about the home. However, quality assurance checks did not always deal with risks promptly, including the call monitor, recruitment checks and consent records.
What inspectors found, December 2023
Rated Good overall; inspectors found safe, kind and personalised care, but the home’s leadership and quality checks require improvement.
The inspection was unannounced and took place on 14 and 17 November 2023. Inspectors spoke with people living in the home, relatives and staff. They observed care and reviewed care plans, staff files and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicines arrangements, suitable training, personalised care plans and respectful support. People were involved in decisions and had access to food, activities and healthcare.
Well-led was rated Requires Improvement. The home’s quality checks did not always identify or reduce risks quickly enough. Inspectors found an issue with the lounge call monitor, two incomplete recruitment checks and consent records that needed improving. The provider was given one recommendation, but no regulation was recorded as breached.
Safe staffing and medicines
Inspectors found enough staff to support people safely. Medicines were stored, given and recorded correctly, with staff training and competency checks in place.
“Medicines were stored, administered, managed safely and accurate records were maintained.” from the report
Kind and respectful care
People were treated with kindness and their privacy, dignity, choices and independence were respected.
“People and their relatives told us staff were caring, considerate and respected their privacy, dignity, and independence.” from the report
Personalised care
Care plans included people’s preferences, history, health needs and the support they could manage themselves. Staff knew people well.
“Care plans contained information about people's personal life, social history, preferences, likes, dislikes, their health and social care needs” from the report
Staff training and healthcare
Staff received training and supervision relevant to people’s needs. The home worked with healthcare professionals when people needed support.
“Training records confirmed that staff had completed training that was relevant to people's needs.” from the report
Quality checks did not always prevent risks
needs fixingThe home’s monitoring systems did not always identify or reduce risks quickly enough. This included the functioning of the lounge call monitor.
“some aspects of their systems were not effective, they had failed to mitigate risks about functioning of the call monitor in the lounge” from the report
Recruitment records
needs fixingTwo staff files had recruitment checks that needed updating. The manager acted on this immediately after inspectors raised it.
“However, 2 staff files recruitment checks required updating.” from the report
Consent recording
needs fixingSome records could suggest that people had consented when they did not have the mental capacity to make that decision. The managers said they would improve the records.
“improvement was required about recording the consent, to ensure records do not indicate consent to care and treatment has been given when people lack mental capacity” from the report
Activity staffing change
minorThe previous activity coordinator had left and the replacement was due to start shortly after the inspection. Activities were still being provided by staff and visiting people.
“the previous activity coordinator had left the service in June 2023, and a new activity coordinator was recruited” from the report
- 01What was wrong with the lounge call monitor, and how do you now check that it is working?
- 02Have the two incomplete staff recruitment checks been updated, and how are recruitment records monitored?
- 03How have you changed consent records for people who may lack mental capacity?
- 04What activities are now available, and has the new activity coordinator started?
- 05What action have you taken in response to the CQC recommendation about quality assurance?
This was an inspection of all five key questions, including infection prevention and control, with care and the premises both considered. This explanation was written from the published report of 30 December 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, July 2021
St. Margarets Residential Home rated Good; inspectors found improvements in safety and leadership, with no current breaches.
Inspectors made an unannounced follow-up visit on 29 June 2021. One inspector and an Expert by Experience spoke with people, relatives, staff and the manager. They reviewed care records, medicines records, staff recruitment files and management records.
The home was rated Good for Safe and Well-led. Inspectors found that risks were assessed, staff followed health professionals' advice, medicines were managed safely and there were enough staff. Infection control measures, including COVID-19 testing, PPE and cleaning, were also in place.
The home had improved since earlier inspections. It was no longer in breach of Regulations 12, 17 or 19. The overall rating changed from Requires Improvement to Good. The other three areas were not assessed during this visit, so their previous ratings were used in the overall rating.
Improved risk management
Care records included relevant risk assessments and staff followed advice from health professionals. Inspectors found the home was no longer in breach of Regulation 12.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Safe medicines
Medicine records were complete, medicines were given as prescribed and storage temperatures were checked. Staff who gave medicines had training and competency checks.
“MAR confirmed that people were receiving their medicines on time and as prescribed.” from the report
Enough staff
Inspectors found staffing levels met people's needs. Recruitment records included checks such as references, criminal record checks and proof of identity.
“During the inspection we observed, and staff told us the staffing levels at the home were meeting people's needs.” from the report
Effective oversight
The manager carried out audits covering areas such as medicines, care plans, accidents and infection control. Safety checks and spot checks were also recorded.
“At this inspection we found that the homes systems for monitoring the quality and safety of the service were operating effectively.” from the report
Positive relationships
Inspectors observed positive interactions between staff and people. Surveys were used to gather views, and feedback led to greater family involvement in care planning.
“Throughout the inspection we observed very positive interactions between people using the service and staff.” from the report
No registered manager yet
minorThe home did not have a manager registered with the CQC at the time of the inspection. The current manager had applied to become registered.
“The service did not have a manager registered with the Care Quality Commission.” from the report
- 01Has the current manager now become registered with the CQC, and if not, what is the progress of the application?
- 02How are people's changing risks reviewed, especially risks relating to falls, diabetes, epilepsy and skin care?
- 03How are medicine audits and staff competency checks kept up to date?
- 04How are relatives involved in planning and reviewing their family member's care?
- 05Have the improvements identified in this report been maintained since the inspection in June 2021?
This was a focused follow-up inspection of Safe and Well-led; the other three ratings were not assessed and were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 22 July 2021 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 Residential Home
7 rated inspections over 8 years: the service has improved, from Requires improvement to Good.
- December 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at St. Margarets Residential Home →
- July 2021GoodSafe: GoodWell-led: Good
Read what inspectors found at St. Margarets Residential Home →
- December 2020Inspected but not ratedSafe: Inspected but not rated
- September 2020Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- July 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2014
Report published without a new overall rating.
- October 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- December 2011
Registered with the Care Quality Commission on 29 December 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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