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

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 requires improvement. At this assessment the

rating has remained 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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always have clear responsibilities, roles, systems of accountability or good

governance.

The provider had systems in place to ensure there was oversight of the services, however,

these were not all robust of effective.

For example, there were areas in the infection control audit that managers completed, that

missed areas of the home, and did not include the oversight of deep cleaning tasks. We found

these areas were neglected or unclean.

Similarly, where systems were in place, these were not being completed to a good standard. For

example, we found there were issues with the system to check the temperature of medicines

storage areas, and for al

the medication audit completed by the registered and deputy managers within the same month, they had marked temperature checks as 100 per cent completion with no concerns identified. On discussions with the provider, they acknowledged the shortfalls and explained they had been overwhelmed with issues relating to human resources in recent months, so their focus had been pulled away from oversight. They told us they were sourcing support in this area from an external organisation to ensure this didn’t happen again, and they implemented further oversight and governance systems. We were not assured about the sustainability of their governance systems and management.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.