St. Margarets Residential Home

Updated 30 December 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 service was inspected by 2 inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

St. Margarets Residential Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

The service was required to have a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. 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

Before the inspection we reviewed the information we held about the service. This included details about incidents the provider must tell us about, such as any safeguarding alerts that had been raised. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We sought feedback from commissioners and the local authority safeguarding team. We took this into account when we inspected the service and made the judgements in this report. We used all this information to plan our inspection.

During the inspection

We spoke with 7 people who used the service and 4 relatives about their experience of the care provided. We spoke with 6 members of care staff, the operations manager, the manager, the registered manager and the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We carried out observations of care provided in the communal areas. We reviewed a range of records. This included 4 people’s care records, 6 staff files in relation to recruitment and a variety of records relating to the management of the service, including policies and procedures.

Updated 30 December 2023

About the service

St. Margarets Residential Home, is a care home providing personal care and accommodation for up to 22 older people in one adapted building. At the time of our inspection there were 21 people using the service.

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

There were systems in place to understand and address the quality and safety issues within the service. The quality assurance system and processes covered aspects such as care plans and care records, medicines management, DoLS authorisations and renewals, night visits, call bells, incident and accidents, staff records, health and safety, and the premises. Regular staff, relatives and residents' meetings were held, and feedback was also sought from people about the service. Staff were complimentary about the manager, the registered manager and the home. The provider worked in partnership with health and social care professionals to ensure people's needs were planned and met. However, some aspects of the quality assurance system and process were not effective to mitigate risks in a timely way.

People and their relatives told us they felt safe. People were safeguarded from the risk of abuse. Staff had received safeguarding training and knew the actions to take to report abuse. Medicines were stored, administered, managed safely and accurate records were maintained. There were enough staff available to support people safely. People were protected from the risk of infection. The provider had a system to manage accidents and incidents.

Staff were supported through regular training and supervisions, so they were able to effectively carry out their roles. People's needs were assessed to ensure they could be met. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff told us they asked for people's consent before offering support. People were supported to have enough to eat and drink and had access to healthcare professionals when required to maintain good health.

People and their relatives told us staff were caring, considerate and respected their privacy, dignity, and independence. They said staff involved them in making decisions about their daily care and support requirements.

People's care plans were reflective of their individual care needs and preferences and were reviewed on a regular basis. People and their relatives were aware of the home's complaints procedures and knew how to raise a complaint. People's cultural needs and religious beliefs were recorded, and they were supported to meet their individual needs. Where appropriate people had their end-of-life care wishes recorded in care plans.

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

Rating at last inspection

The last rating for this service was good (published 22 July 2021).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Enforcement and recommendations

We made 1 recommendation about improving quality assurance system and processes in good governance.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.