Margaret's Rest Home

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• 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the

rating has remained 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 management of medications and

infection prevention and control.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider made sure there were enough qualified, skilled and experienced staff, however,

they did not ensure that supervision and support was regular and effective.

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.

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 used a matrix to track staff training needs and competency assessments. We

reviewed these as part of the assessment, and training was very close to 100 per cent. We

found no concerns with their management of competency assessments.

The provider did not always assess or manage the risk of infection. They did not always detect

and control the risk of it spreading.

We found that staff were wearing appropriate jewellery (for example, plain wedding bands), and

shoes that were easy to clean material which supported good infection control. However, we

found that staff were wearing non-uniform items, such as long sleeved tops and cardigans,

which increases the risk of infection spreading if worn during the delivery of personal care tasks.

We found areas of the home that were dusty and visibly unclean. For example, and soap dish in

one of the communal bathrooms was very dirty, which was also an issue identified at our

previous inspection. We found some rooms were unclean and dusty, and there was not a robust

system in place in relation to deep cleaning people’s bedrooms. This meant that only a small

number of rooms were being deep cleaned and sometimes it was the same rooms completed

without a system to make sure there was a fair distribution of deep cleaning.

The provider did not always make sure that medicines and treatments were safe. We found that the provider had systems to ensure safe storage of medication, including lockable doors and cabinets, as well as systems to check the temperature of storage to ensure medicines were not spoiled. However, they had recently (the beginning of January 2026) introduced a new system whereby staff should check the fridge and room temperature of the medication storage room, twice a day. This had consistently only been completed in the morning and not in the evening. There was a process in place for staff to follow, should they find the temperature was too hot or cold. This was clearly documented on the form in place for staff to complete. The day of the inspection, and the 3 days prior, the fridge temperature was too high. This had not been escalated, and therefore not addressed, as per the providers process, and the registered manager was not aware of this. We found medicines in the building that had been discontinued the previous month, and not returned to the pharmacy, or even removed from the medication storage area. Additionally, we found expired eye drops and some medicines for one person, were found in another person’s medication stock.