Margaret's Rest Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to oversight of the service.

This service scored 46 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. We found during our assessment, a closed culture in the organisation. Some staff were afraid to speak up through fear of reprisal, and we were not assured by the end of our assessment that this would effectively be addressed. Some staff felt that there was a blame culture at the service, and we observed occasions where the priority was to establish who had raised the issue, as opposed to resolving the issue.

The providers vision statement states that they are committed to person centred care, however we were not assured at the end of our assessment that care was person centred.

The provider is currently working with a consultancy organisation, through an action plan to improve their service.

Leaders did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The providers and Registered Managers did not always have good oversight of the service and failed to embed learning into wider practices and systems.

They did not always lead by example. For example, the unsafe storage of medication was a practice that the provider and Registered Manager overlooked in their system for storing the next cycle of medication, but, we observed staff being held to a higher standard and when they made medication errors, this fed into performance management plans and documented discussions.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Some staff had recently raised concerns with the provider, and other organisations, of unfair treatment and favouritism. One member of staff told us that they had recently seen improvements to this, however, others were still concerned this was an issue. The provider had recently changed their Nepotism policy to ensure people would not directly line manage someone they have a personal relationship with, for example, a relative. This was not yet embedded into practice. Supervisions were completed every 3 months, but some staff raised concerns about the efficacy of their supervisions.

The provider had a diverse workforce, including people with protected characteristics. Staff were able to undertake tasks required for their religion, for example, praying, during their shifts and they were not required to undertake tasks that infringe on their beliefs. The provider was working with a consultancy organisation for human resources processes and support for their workforce.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them. Some staff had recently raised concerns with the provider, and other organisations, of unfair treatment and favouritism. One member of staff told us that they had recently seen improvements to this, however, others were still concerned this was an issue. The provider had recently changed their Nepotism policy to ensure people would not directly line manage someone they have a personal relationship with, for example, a relative. This was not yet embedded into practice. Supervisions were completed every 3 months, but some staff raised concerns about the efficacy of their supervisions.

The provider had a diverse workforce, including people with protected characteristics. Staff were able to undertake tasks required for their religion, for example, praying, during their shifts and they were not required to undertake tasks that infringe on their beliefs. The provider was working with a consultancy organisation for human resources processes and support for their workforce.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Quality assurance processes were in place where necessary, however, we were not assured these processes were being followed. For example, there was a requirement to check the water temperature of taps around the home. We found logs that were completed on a weekly basis. The most recent checks identified that all taps were running at the correct temperature, however, we found taps running below the required temperature, and people told us this had been like this for a long time. This was fed back to the provider who told us they were not aware of this and addressed it promptly.

Care plan reviews were undertaken monthly, however we were not assured these were always effective as some care plans had out of date and irrelevant information in them, for example, medications that were no longer prescribed to the person and hadn’t been for some time.

Some processes were not clear and left people at risk of delays in receiving the right care and support. For example, the on-call system, which is management support out of normal working hours, was not clear or robust. The responsibility lay with one person, and there were gaps in the process for when this person is not available. There was also not a clear process in place for who was responsible for attending the service in all situations.

Business continuity plans were in place, and the provider is planning a practice evacuation of the service to ensure the plans in place are effective and safe.

Systems were in place for sharing information such as, notifying the local authority and regulator about incidents. The provider was working to an action plan set out by the local authority to make improvements to the service.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

We found some evidence during our inspection of good collaborative working. The Registered Manager was part of a group of Registered Managers from other organisations, where tips, advice and support can be sought and shared. Referrals were sent where people needed to access care, support and treatment however, we were not assured this was taking place consistently for all people.

The provider was working through an action plan with a consultancy organisation to improve their service.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. During our assessment, we were not assured that there was effective learning from incidents, complaints or concerns raised with the provider. The provider’s approach was more reactive, than proactive. They did not apply learning from events to wider systems or practices, but they did address some isolated events, leaving the opportunity for similar events to reoccur, or the same events to happen in other areas of the service. For example, in November 2024 they had a mock inspection done by a consultancy organisation, and they identified an issue of the medication room door not being locked for safe storage of medicines. Recently, daily walkarounds had been put in place for both the senior carers and Registered Manager to complete. These did not identify the medication room or safe storage of medicines as an area to check.

The senior staff walkarounds were not utilised in the best way and did not contain information that could contribute to learning and improvement, some were left incomplete.

The provider did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. Some staff told us that they did not feel hard work was recognised and appreciated by the provider which in turn deters staff from sharing ideas and making suggestions. We found during our assessment an employee of the month scheme. We were told that the staff member is sometimes chosen by the Registered Manager and sometimes it is based on feedback from persons or relatives.