- Care home
Margaret's Rest Home
Assessment report published 10 June 2025
Contents
Ratings
Our view of the service
Date of Assessment: 20 March to 10 April 2025. The service is a residential care home providing support for up to 27 adults of all ages with dementia and physical disabilities.
The provider was in breach of 3 legal regulations relating to safe storage and management of medications, managing risks, restrictive practices and oversight of the service.
The provider did not always have systems to identify, assess, monitor and mitigate risks to people’s safety and welfare. Where systems were in place, the provider did not always have sufficient oversight to ensure they were effective.
The provider did not always identify and respond to risks in a timely manner, where they had identified risks, or addressed complaints and incidents, they did not always embed learning into wider practices and systems.
The providers judgment on practices was not always in line with best practice or regulations, meaning choice and control over people’s care was not always upheld.
The provider was very receptive to feedback during our inspection and was working with a consultancy organisation on an action plan to become compliant and improve the service for the people living in the home, relatives and staff. This was ongoing before and during our inspection.
The provider was in the process of developing person-centred care plans with the persons involvement as well as their relative’s input.
The provider supported people as individuals, encouraged and supported different values and beliefs. However, this was not consistent for everyone using the service.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.
We have asked the provider for an action plan in response to some of the concerns found at this assessment.
People's experience of this service
Feedback from people using the service was mixed. Overall, people told us they were happy with communication and the provider had been open and honest when mistakes were made, including when accidents had happened, such as falls. One person said, “They (the provider) are quick to let us know anything”. People felt that staff were polite and respectful, but there was not enough of them.
People said they were not involved in the planning of care and would have liked to have been, although they acknowledge that they are involved in reviewing their care and support needs at least twice a year.
People felt that when they raised concerns, they were either not listened to, or things improved for a period of time before reverting to how it used to be. One relative said, “Whenever I raise an issue, an explanation is provided and it improves for a while, then goes back”. People felt that the laundry process was ineffective and despite raising concerns, nothing had been done.
People raised concerns with the cleanliness and the support they received with personal hygiene. One person told us that they deep clean their relative’s room every fortnight as it gets so dirty. People reported finding their relatives in undignified and unhygienic situations. One relative had been told to expect to find their relative like this as it was the nature of their condition, by a member of staff.
People raised concerns with the environment. One person described it as “tired and worn”, others felt the décor was outdated and the place was generally rundown.
Some people could not directly tell us about their experience. We used observations to assess whether they received good care. This showed mostly positive interactions between people and staff.