Margaret's Rest Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation relating to safe storage of medicines and managing risks.

This service scored 44 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. For example, the provider did not have effective systems and processes in place for managing personal relationships amongst staff, until an increase in concerns around unfair treatment were raised to external organisations, and a serious incident happened. These systems had been developed prior to our inspection but not embedded into practice yet.

Lessons were not always learnt to continually identify and embed good practice. For example, on day 1 of our inspection, we found some of the same issues that were identified during a mock inspection undertaken by a consultancy organisation in November 2024. This included unsafe storage of medications. Learning had not been applied from the mock inspection around the safe storage of medication. This meant that people were at risk of accessing medicines. Changes to these processes are now being embedded into practice.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care. Following concerns being raised by healthcare professionals regarding staff’s knowledge of people’s medical needs, the provider/Registered Manager had implemented new hospital passports containing relevant and key information about people for better transitions to other services in an emergency situation. We found these could be more succinct to provide vital information quickly.

Feedback gathered by inspectors from health professionals working with the service was positive.

The provider did not work well with people to understand what being safe meant to them and how to achieve that. People said they were not involved in the planning of care; however, the Registered Manager was in the process of developing new person-centred care plans with people and their relatives.

The provider did not always concentrate on improving people’s lives or protecting their right to live in safety, free from abuse, avoidable harm and neglect. We found a member of staff’s safeguarding training had expired, but nothing had been put in place to safeguard people in their care.

We were not assured the provider had good oversight of safeguarding as there was a fear amongst the staff team to report. Some staff reported they had witnessed colleagues receive “backlash” from reporting concerns to external organisations before. This leaves people at continual risk of abuse.

We observed restrictive practices in place for example, tables being placed in front of people, so they were not free to move around. This practice changed following our feedback, and we were assured that this was no longer taking place.

There was a lack of knowledge of Duty of Candour amongst staff, however, people and relatives reported they were kept informed of accidents and incidents.

The provider did not always work well with people to understand and manage risks. We found that some people were supported to understand and manage risks, for example, one person wanted a standalone heater next to their bed. The Registered Manager ensured the person understood the risks, including scalding, and there was a care plan and risk assessment in place around this. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Not everyone was supported in this way. We found that a small number of people were supported with meaningful activities, for example, the Registered Manager is organising attendance to a rock concert for one person, whilst others are not supported effectively to explore risks they want to take for a better quality of life.

The provider did not always detect and control potential risks in the care environment.

We found the environment to be cluttered, including moving and handling equipment being stored in corridors. A risk assessment was put in place following this feedback; however, it was not sufficient and did not identify impact or specific actions to mitigate risks. On two occasions, moving and handling equipment was seen blocking a fire exit, this was only moved once inspectors had fed this back to the Registered Manager. This left persons at increased risk of injury from trips and falls, and delayed evacuation in an emergency.

The provider had identified some issues with the environment prior to our inspection and were already taking action to fix them, such as faulty, and aged safety gates at the top and bottom of staircases.

The provider is changing the way they store equipment and other items, as well as working to a maintenance plan to make the environment safer. We were assured they are taking this issue seriously, but this was not fully embedded into practice by the end of our inspection.

The provider did not always make sure there were enough qualified, skilled and experienced staff. People using the service and staff told us there was not enough staff on shift, however, we did not observe this during our inspection. The provider used a dependency tool to establish the number of staff required based on people’s individual care needs. New staff recruitment processes in place were good, and there were many long-standing members of staff with over 6 years at the service. However not all staff were up to date with their training at the time of inspection.

Where agency staffing was needed at times to cover shifts, they used the same agencies and where possible, the same staff members for consistency. Agency staff members profiles were received and checked before they attended the home for work.

The provider did not always make sure staff received effective support, supervision and development. Most staff told us their supervisions were short and ineffective. Some staff were apprehensive to reach out for support, saying they were concerned their confidentiality may not be respected. The provider was not aware of this concern so had been unable to address it at the time of inspection.

Staff did not always work together well to provide safe care that met people’s individual needs. Some staff fed back that there is a lack of respect amongst the staff team. Some said there can be lots of gossiping and there is a blame culture. The provider, Registered Manager and consultancy organisation are in the process of planning and hosting team building days to address issues such as this.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found unsafe storage of medication on day 1 of our inspection. We found the medication room unlocked and unsupervised with the keys inside the room in an area accessible to people, external professionals and visitors. A similar issue had been identified during a mock inspection in November 2024, completed by a consultancy organisation. We were not assured that this practice would stop.

We found a 4-week stock of medicines being stored in the Registered Manager’s office on day 1 of our inspection. On multiple occasions this room was found to be open, and unsupervised by staff. This area was accessible to people, external professionals and visitors. This left people at risk of accessing a large quantity of medicines. There was no system or process in place to ensure the room was at the right temperature for safe storage of medicines. A new system and process was embedded by the end of our inspection.

Where people were unable to understand the risk of refusing their medication, the correct process had been followed to implement covert medications. This meant that people were being given medication without their knowledge, following a mental capacity assessment, and best interest process that involved the GP, Pharmacist and the person’s relatives. We found that people received their medications as prescribed.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We found unsafe storage of medication on day 1 of our inspection. We found the medication room unlocked and unsupervised with the keys inside the room in an area accessible to people, external professionals and visitors. A similar issue had been identified during a mock inspection in November 2024, completed by a consultancy organisation. We were not assured that this practice would stop.

We found a 4-week stock of medicines being stored in the Registered Manager’s office on day 1 of our inspection. On multiple occasions this room was found to be open, and unsupervised by staff. This area was accessible to people, external professionals and visitors. This left people at risk of accessing a large quantity of medicines. There was no system or process in place to ensure the room was at the right temperature for safe storage of medicines. A new system and process was embedded by the end of our inspection.

Where people were unable to understand the risk of refusing their medication, the correct process had been followed to implement covert medications. This meant that people were being given medication without their knowledge, following a mental capacity assessment, and best interest process that involved the GP, Pharmacist and the person’s relatives. We found that people received their medications as prescribed.