St Margarets Nursing Home

We found the following examples of good practice.

Staff and the registered manager had worked hard to contain this outbreak within the service. Staffing absences due to Covid-19 infections had been low, and their shifts had been covered by existing staff and the registered manager. No agency staff were used.

There was a designated area for receiving all visitors to the service, checking their vaccination status and their Covid-19 self test result. Masks, aprons and hand sanitiser was readily available throughout the service.

We spoke with four people who told us "I go out every day for a walk around the corner, I don't speak to anyone or go in to any shops but I enjoy the exercise," "I see my family regularly, they come here and I speak with them on the phone," "I have my son come but he did not think it was a good idea during this outbreak so I will see him soon now we are nearly out of it."

We were assured that this service met good infection prevention and control guidelines.

We found the following examples of good practice.

The home was visually clean and free from odours. There were procedures to ensure that infection control risks were reduced. For example, planned increased cleaning of communal areas and high touch areas such as door handles and light switches. Following the inspection the registered manager provided assurances that cleaning schedules and checklists for increased cleaning of high touch areas such as door handles and handrails were implemented.

Training had been provided to staff regarding donning and doffing personal protective equipment (PPE). Plentiful supplies of PPE and handwashing facilities were seen. This included masks, gloves, aprons, gowns, visors and goggles. We saw most staff wore their PPE correctly. However, we observed one member of staff whose mask was not covering their nose fully while in communal areas of the home and another who frequently adjusted their mask as it slipped from their nose. The registered manager stated this would be addressed promptly.

Procedures were in place regarding self-isolation for people who were admitted to the home from the community or other health care provision. The admission procedure had been reviewed and developed to reduce the risk of infection from COVID-19.

The home had a contingency plan to reduce the risk of cross infection should there be an outbreak of COVID-19 in the home. This included self isolation for residents who showed symptoms and separating staff teams so they cared for a reduced number of people and only one group of staff cared for residents who had tested positive for COVID-19. This would reduce the risk of cross infection.

Due to the current national lockdown, visiting was restricted. The home had a visiting policy and procedure and had advised family and friends of these arrangements by letter. Arrangements had been made to resume visiting with access to the home via the sun room, in which the visit would take place. Visitors were screened for COVID-19 prior to entering the home. Visitors would be required to wear masks and, as necessary, other protective personal equipment (PPE). This helped to reduce the risk of infection being brought into the home.

Where visiting was allowed for compassionate reasons (for example for people receiving end of life care), suitable infection control procedures were followed when visitors entered and moved around the building

People were supported to speak with their friends and family using IT systems and the telephone as necessary.

Appropriate testing procedures for COVID-19 had been implemented for all staff and people who used the service following national guidance regarding the frequency and type of testing. Staff only worked at the home and no agency or bank staff were used. This reduced the risk of cross infection.

The staff monitored residents for symptoms of COVID-19. This included routinely monitoring physical symptoms such as temperature checks every three days or when other symptoms were noted.

Infection control policies and procedures had been updated in line with the national guidance relating to COVID-19. Staff had access to the policies and procedures including updates. The training for staff regarding infection control had been updated to include guidance relating to COVID-19.

The registered manager had completed risk assessments and audits / checks regarding the environment and risks to staff and residents.

The registered manager had discussed with the staff those who may be at increased risk from COVID-19. The registered manager planned to complete individual risk assessments for each member of staff to formally identify those who were at increased risk from COVID-19 and the measures that would be required to keep them safe, should there be an outbreak in the home.

Staff breaks were staggered to reduce the risk of groups of staff congregating together.

This unannounced comprehensive inspection took place on 15 November 2018. The last comprehensive inspection took place on the 5 December 2017 when the service was not meeting the legal requirements. We issued a warning notice against the service due to repeated breaches of the regulations. The service was rated overall as Requires Improvement at that time.

We carried out a focused inspection on the 8 February 2018 to review the actions taken by the service to meet the requirements of the warning notice. At that time, we inspected the service against two of the five questions we ask about services: is the service well led and is the service safe? No risks, concerns or significant improvement were identified in the remaining Key Questions through our ongoing monitoring or during our inspection activity so we did not inspect them. The service had taken action to address the concerns we had regarding fire door closures, oxygen signage and very hot water coming from the hot taps in sinks used by people living at the service. We had been concerned that there were not enough appropriately sized moving and handling slings to meet people’s needs. At the focused inspection we found the service had ensured each person had their own appropriately named sling. Infection control issues highlighted at the December 2017 inspection regarding overflowing bins without lids, and sluices which were unlocked had been addressed. Staff recruitment had been reviewed to ensure all staff had appropriate checks completed before commencing working at the service. Whilst the service had met the requirements of the warning notice we required a period of embedded and sustained improvement before the overall rating of the service was changed. We carried out this comprehensive inspection to review the service’s overall rating.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

We spent time in the communal areas of the service. Staff were kind and respectful in their approach. They knew people well and had an understanding of their needs and preferences. People were treated with kindness, compassion and respect.

People told us, "There is always enough staff. I can talk to any of the staff if I was worried and they listen and help you. One carer is one of the best, they know me and I know I don’t need to worry about anything whilst they are around,” “They (staff) do make sure I have my medication on time especially my Insulin. They always ask if I am in pain and if so they will give me something to ease the pain.”

The service was warm, comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes. The service had some pictorial signage to support people who were living with dementia, who may require additional support with recognising their surroundings. The premises were regularly checked and maintained by the provider. Equipment and services used at St Margaret's were regularly checked by competent people to ensure they were safe to use.

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs were recorded. Daily notes were completed by staff.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. The service had no staff vacancies at the time of this inspection.

There were systems in place for the management and administration of medicines. It was clear that people had received their medicine as prescribed. Regular medicines audits were being carried out on specific areas of medicines administration and these were effectively identifying if any error occurred such as gaps in medicine administration records (MAR).

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy. People told us, “There is always plenty to drink but I like to have a beer a day and friends bring that in,” “I think meals here are second to none. Fantastic and a lot of choice, I always eat in the dining room and food is hot if meant to be hot” and “I eat very little. The food here isn’t too bad and you get a couple of choices. I eat in my room as the meals are at set times.”

People had access to activities. An activity co-ordinator was not in post but care staff shared the provision of activities. There was little recording of who attended activities and if people enjoyed them. People told us they were bored, and “There are no activities here apart from watching TV,” “I would say no activities take place here, very little goes on here. I like a singer but she only comes once a month. We do have fish and chips Fridays. which I look forward to.” We discussed this with the registered manager who assured us they would discuss the provision of relevant and meaningful activities with people. We have made a recommendation about this in the Responsive section of this report.

The use of technology to help improve the effectiveness of care provision was limited. People did have call bell to summon assistance when needed.

Staff were supported by a system of induction training, supervision and appraisals. The registered manager had records that enabled them to have an overview of staff support requirements.

Risks in relation to people’s daily life were assessed and planned for to minimise the risk of harm. However, we found some care plan reviews did not always incorporate a review of all risk assessments.

People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies to support staff with current guidance.

People's rights were protected because staff acted in accordance with the Mental Capacity Act 2005. The principles of the Deprivation of Liberty Safeguards were understood and applied correctly. However, some consent forms had been signed by family members who did not hold the legal power to consent on behalf of another person. The registered manager addressed this during the inspection.

There were effective quality assurance systems in place to monitor the standards of the care provided. Audits were carried out regularly by nurses and senior management staff. However, we identified that some aspects of the care plan reviews were not always robust.

The registered manager was supported by a deputy manager, the provider and a team of motivated and long standing staff. The staff team felt valued and morale was good.

Staff told us, “I am happy here, we get good support,” “In all the years I have been here I think this is the best St Margaret's has ever been” and “We all get on and it's like a family.”

The service was rated as Requires Improvement at the last inspection. Identified safety concerns included very hot water running from the taps in people's ensuite bathrooms and communally used toilets, posing a scalding risk to people using the hot water. One person's bedroom door closed shut very quickly and heavily posing a risk of injury to the person using this room. We also identified a number of fire doors to people's bedrooms that were propped open with door wedges. This placed people at risk in the event of a fire near to their bedroom. We advised the service to fit devices to the fire doors which allow the doors to be held open when needed but close when the fire alarm sounds. In December 2017 we identified infection control issues including overflowing bins and inappropriate storage of people’s slings, which were being routinely stored with staff coats. As a result of ongoing concerns enforcement action was taken.

Following the last inspection the service sent us an action plan stating what action it was taking to meet the requirements of the regulations. This inspection visit was planned to check on the action the service had taken to meet the requirements of the regulations.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. St Margarets is a care home which offers care and support for up to 28 predominantly older people. At the time of the inspection there were 26 people living at the service. Some of these people were living with dementia. The service uses a detached house over two floors with a passenger lift for people to access the upper floor.

At this inspection we found maintenance work had been carried out to ensure the hot water system was safe to use and did not exceed recommended temperatures for a domestic hot water supply. We checked all hot water supplies and found these were not excessively hot. Daily temperature checks were carried out to ensure the system was consistent. There was also a monthly audit of maintenance check of the hot water system. People told us they had not experienced any recent issues with the temperature of water at the service.

The service had taken actions regarding concerns about the maintenance and use of fire doors. A fire door previously identified as having a faulty closure device had been fixed. We saw the door was now held open by a device connected to the fire alarm system which automatically closed in the event of a fire. All other fire doors were working effectively and none were being wedged open by furniture as had been previously identified. Appropriate signage and safety procedures were in place for a person who used oxygen in their room. The premises, equipment and services were regularly checked and maintained by a maintenance person or other competent people.

At the last inspection in December 2017 staff told us there were insufficient numbers of appropriate sized moving and handling slings for all the people who needed them at St Margarets. No-one was sharing slings at this inspection as the service had purchased new slings to accommodate people’s individual size requirements. Previous concerns about cross infection due to slings being stored beside staff coats had been addressed by the service. We saw that slings were being stored appropriately away from shared areas.

Infection control concerns highlighted at the inspection in December 2017 regarding overflowing bins had been addressed. The service had purchased additional bins to dispose of food waste and aprons and gloves used by staff separately. Sluice rooms were kept locked when not in use. This meant people were protected from accessing hazardous substances stored in these rooms.

At the last inspection we found safe recruitment checks had not been carried out for one staff member. We reviewed recruitment practices at the service. The registered manager was in the process of recording Disclosure and Barring (DBS) check numbers for all staff employed at the service. In undertaking this process it had come to light that there was not a current DBS number recorded for one staff member. The registered manager told us this was an administrative error as the staff member had worked for St. Margarets for a considerable time. A new application for an updated DBS check was made to ensure all staff had appropriate checks and were safe to work with vulnerable people.

There were systems in place for the management and administration of medicines. People had received their medicine as prescribed. Regular medicines audits were being carried out on specific areas of medicines administration and these were effectively identifying if any error occurred such as gaps in medicine administration records (MAR).

We walked around the service which was comfortable and appeared clean with no odours. People's bedrooms were personalised to reflect their individual tastes. People were treated with kindness and compassion. People clearly had good relationships with staff who supported them.

Staff were supported by a system of induction training, supervision and appraisals. People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies to support staff with current guidance. Mandatory training was provided to all staff with regular updates provided. The manager had a record which provided them with an overview of staff training needs.

The service had identified the minimum numbers of staff required to meet people's needs and these were being met. The service had no staff vacancies at the time of this inspection.

Following the last inspection the service sent us an action plan stating what action it was taking to meet the requirements of the regulations. This inspection visit was planned to check on the action the service had taken to meet the requirements of the regulations.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. St Margarets is a care home which offers care and support for up to 28 predominantly older people. At the time of the inspection there were 26 people living at the service. Some of these people were living with dementia. The service uses a detached house over two floors with a passenger lift for people to access the upper floor.

At this inspection we again found very hot water coming from the taps in the ensuite bathrooms of two people who used the hot water in their rooms independently. We also found very hot water coming from the taps in a communally used bathroom. Signs throughout the service stated the water was very hot and in a shower the sign stated the hot water posed a scald risk.

At this inspection we identified a person’s bedroom door was slamming shut quickly and heavily. The door closure device was faulty. This was the same bedroom door identified as a concern at the May 2016 inspection. This door was not being held open by the device which was connected to the fire alarm system, which closed in the event of a fire, but by an ornament which would not allow the door to close in an emergency. This put the disabled person in this bedroom at risk.

At this inspection we found people’s bedroom doors continued to be held open by items other than fire system devices. One person, whose door was wedged open by furniture, was using oxygen in their room, there was no door guard on the door and no sign on their door to alert people to the use and storage of oxygen in their room. This meant the person was at considerable risk in the event of a fire.

Staff told us there were not sufficient numbers of appropriate sized moving and handling slings for all the people who needed them at St Margarets. Nine people were sharing slings. Some people required large sized slings which were not available to them. This meant people were at risk of not being moved safely and appropriately. Sharing slings does not protect people’s dignity and is a cross infection risk.

Slings were hung together on hooks in the corridor. Staff hung their outside coats, scarves and jumpers on these same hooks. This increased the risk of cross infection. Open bins, without lids, were used for food waste in the dining room. Staff also used this bin for their soiled gloves and aprons. Open bins without lids were also found in toilets, overflowing with used paper towels.This also posed a risk of cross infection.

Sluice rooms were found open and containing substances hazardous to people’s health. The medicines room was found open and unattended. There were people living at the service who were independently mobile and living with dementia, this meant they were at risk of accessing items which could pose a risk to them.

Recruitment checks for new staff were not robust. One member of staff, who had been working at the service for six months, had not had all the appropriate recruitment checks carried out by the previous registered manager. There was no current Disclosure and Barring Check held by the service to ensure the person was safe to work with vulnerable people.

Some people living at St Margarets were living with dementia. Some were able to walk around the service independently. However, there was no pictorial signage at the service to support people who may require additional support with recognising their surroundings. One communally used toilet did not have a lock on the door. This meant people’s privacy was not protected.

There were systems in place for the management and administration of medicines. People had received their medicine as prescribed. Regular medicines audits were being carried out on specific areas of medicines administration and these were effectively identifying if any error occurred such as gaps in medicine administration records (MAR).

The premises, equipment and services were regularly checked and maintained by a maintenance person or other competent people. However, the hot water and door closure concerns found at this inspection had not been highlighted by these checks.

We walked around the service which was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes. People were treated with kindness and compassion.

Staff were supported by a system of induction training, supervision and appraisals. People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies to support staff with current guidance. Mandatory training was provided to all staff with regular updates provided. The manager had a record which provided them with an overview of staff training needs.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. The service had no staff vacancies at the time of this inspection.

People's rights were protected because staff acted in accordance with the Mental Capacity Act 2005. The principles of the Deprivation of Liberty Safeguards were understood and applied correctly.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. However, pureed meals were not presented in an appetising way. All the meal was mixed up together to a brown consistency instead of each component of the meal being pureed separately. Staff were available to support people to eat if required. We noted that some people had their clothes protectors left on throughout the morning, and for some time after breakfast. This did not protect their dignity.

Care plans were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs were recorded. Daily notes were completed by staff.

People had access to activities. An activity co-ordinator was not in post but care staff co-ordinated activities. On the day of this inspection school children came to entertain people. People were supported to go out on trips in to the local community.

The day to day running of the service was overseen by a deputy manager, who was supported by the registered manager and an administrator. The registered manager visited the service regularly as they were also the registered manager for another service. The service had a team of happy, motivated and many long standing staff.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

St Margaret's Nursing home offers nursing care and support for up to 28 predominantly older people. At the time of the inspection there were 27 people living at the service. Some of these people were living with dementia. The building is a detached house over two floors. There is a passenger lift that provides access for people to the upper floor.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection we identified very hot water running from the taps in people’s ensuite bathrooms and the basin in a separate toilet in the upstairs corridor. There were signs above each sink stating, “Caution very hot water.” This posed a scald risk to vulnerable people using the sinks. At this inspection we found that the maintenance man had taken action to help to reduce the temperature of the water in the hot taps by reducing the temperature of the boiler. He also carried out regular checks of the temperature of water in people’s rooms and toilets. We checked the temperature of hot water in two sinks on the first day of our inspection, it was over 45 degrees centigrade. We were told staff had turned on the electric immersion to override the boiler and this made the water hotter than it should be. On the second day of our inspection, the hot water was at a slightly lower temperature when checked.

At the last inspection we identified doors to people's bedrooms slammed shut very quickly and loudly. This posed a risk of injury to people using these doors. At this inspection we found the doors closed slower as they had been adjusted.

At the last inspection we identified staff training, supervision and appraisal was not being provided in accordance with the policy held by the service. Some staff had not attended mandatory updates such as health and safety and moving and handling. At this inspection we found regular supervision for most staff was being provided and annual appraisals had taken place for most staff. However, although some training had been provided to some staff since the last inspection, some mandatory training was still required by some staff. The registered manager told us they had been required to work more nursing shifts recently to cover for staff taking leave, and this had hindered their progress with this training provision. We saw staff had been provided with paper based training packages which they were working on at the time of this inspection.We have recommended that the registered manager addresses this concern immediately

At the last inspection we identified there were a number of fire doors to people's bedrooms that were propped open with door wedges. Some people, whose bedroom doors were wedged open, were cared for in bed due to their healthcare needs. We saw that people had signed disclaimers, saying they were happy to have their doors wedged open. However, this practice was not safe and meant that people would not be protected in the event of a fire near to their bedroom. We advised the service to fit devices to the fire doors which allow the doors to be held open when needed but close when the fire alarm sounds. At this inspection we found fire doors to many people’s bedrooms and corridors were still being wedged open. The provider had commissioned two independent fire professionals to carry out surveys in July 2016 and August 2016. Both reports clearly recommended that all door wedges be removed immediately and devices fitted to them to allow them to close in the event of a fire alarm being activated. This had not been done. We contacted the provider who assured us that this work would be carried out immediately. Following the inspection visits we were provided with evidence that some fire doors had been fitted with automatic closures linked to the fire system. Further assessment was being carried out to establish how many people’s bedroom doors would require further door guards to be fitted. We were given assurances by the provider that this work would be carried out immediately.

The service had an internal passenger lift. This was the only internal access for people who lived upstairs to get down to the lounge and dining room and back up to their rooms. An intermittent fault to the lift had been reported. This lift had been serviced in September 2016. There had been actions advised for, “Further work to be undertaken” and specific parts that were required. The registered manager or the provider was not able to provide us with any evidence that this advice had been carried out. There were no risk assessments for the event of anyone becoming trapped in the lift, or if it ceased to work for a time. However, we were assured that there was an external route around the back, outside of the service, where a ramp would provide emergency access for people on the upper floor.

We walked around the service which was comfortable and personalised to reflect people’s individual tastes. People were treated with kindness, compassion and respect.

We looked at how medicines were managed and administered. We found it was possible to establish if people had received their medicine as prescribed. Medicines were stored, recorded and administered safely. Regular medicines audits were consistently identifying when any errors occurred.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. The registered manager had needed to cover more shifts than usual when nursing staff took leave. Agency staff were not used by the service.

Staff meetings were held for all staff groups. These allowed staff to air any concerns or suggestions they had regarding the running of the service. Staff told us they felt very supported by the registered manager.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Staff supported people with their meals if required.

Care plans were well organised and contained information for staff on how to meet people’s needs. Care plans were reviewed regularly, however people’s changing needs were not always recorded in a timely manner. This led to some care plans being inaccurate in the guidance they provided for staff. People, and where appropriate, relatives were included in the reviews.

Activities were provided for people both in and outside of the service. Entertainers regularly visited and planned activities happen some days. Bus trips took place every two weeks to take people out in to the local area.

The registered manager was supported by a clinical lead nurse, senior care staff and a team of motivated care and ancilliary staff.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see what action we have told the provider to take at the end of the full version of this report.

St Margaret's Nursing home is a care home which offers nursing care and support for up to 28 predominantly older people. At the time of the inspection there were 28 people living at the service. Some of these people were living with dementia. The building is a detached house over two floors. There is a passenger lift that provides access for people to the upper floor.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The current registered manager had only been formally in post since January 2016 and had started a programme of improvements to the service. There was evidence of improvement at the service which is detailed in the main section of this report.

During this inspection we identified very hot water running from the taps in people’s ensuite bathrooms and a separate toilet in the upstairs corridor. There were signs above each sink stating, “Caution very hot water.” Whilst it was not possible to accurately record the temperature of this hot water we asked the registered manager to accompany us to several sinks and experience the hot water coming from the taps. The registered manager agreed it presented a potential scalding risk to people. Some people used their ensuite bathrooms independently and were experiencing a varying degree of physical and mental impairment. This meant they were at an increased risk from being scaled by very hot water.

We identified doors to people’s bedrooms slammed shut very quickly and loudly. This posed a risk of injury to people using these doors.

At the August 2015 inspection we found that staff had not always received necessary training updates. Supervision and appraisals were not provided for all staff in accordance with the policy held by the service, which stated all staff should have supervision every six months and appraisals annually. The staff records relating to training, supervision and appraisal were not monitored and not always accurate. Some staff had not attended mandatory updates such as health and safety and moving and handling. At this inspection we found that the newly registered manager had focused on the care staff support. Training updates, supervision and appraisals for all the care staff were being provided. However, the nursing staff still needed training updates. Only the registered manager and the clinical lead had received supervision in the last six months. We were told some members of the nursing staff team had showed some resistance to attending training updates and having regular supervision. This was being addressed by the new registered manager, who was using the revalidation process being undertaken by the nurses during 2016 to ensure all nurses had attended recent training.

At the August 2015 inspection we found items in the medicine trolley that had been prescribed for people no longer at the service. At this inspection we found the medicine trolley only contained items that had been prescribed for people living at the service. We looked at how medicines were managed and administered. We found it was always possible to establish if people had received their medicine as prescribed. Regular medicines audits were consistently identifying if errors occurred.

At the August 2015 inspection we found that care staff had not received recent safeguarding adults training updates. At this inspection we found there was a programme in place for all staff to undertake this training. However, some nurses still needed to attend a refresher of this training. Staff we spoke with were clear about how to recognise abuse and report any concerns they may have appropriately.

At the August 2015 inspection we found that some people needed to have their blood sugar monitored regularly and staff were not always following this guidance in people’s care plans. At this inspection we found the service had a system in place which helped ensure people who required such regular monitoring had this support provided.

At the August 2015 inspection we found there were no Personal Emergency Evacuation Plans (PEEPs) available for people living at the service. At this inspection we found there was an emergency file containing all the contact details for people’s families along with their mobility and equipment needs in the event of an emergency evacuation of the service being required. This meant people could be safely moved if necessary.

At the August 2015 inspection we found that new staff had not always provided adequate references. There was no record of new staff having an induction checklist completed to help ensure this issue was identified. At this inspection we found new staff had provided adequate references and there had been an induction checklist completed detailing all checks as they were completed. This meant people were protected from the risks associated with being cared for by staff who were not suitable for the role.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met.

We walked around the service which was comfortable and personalised to reflect people’s individual tastes. There were no malodours at the service throughout this inspection. People were treated with kindness, compassion and respect.

Staff meetings were held. These allowed staff to air any concerns or suggestions they had regarding the running of the service and helped ensure good communication across all staff groups.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy.

Care plans were well organised and contained accurate and up to date information. Care planning was mostly reviewed regularly and people’s changing needs recorded. Where appropriate, relatives were included in the reviews.

Activities were provided at the service. However, there was no programme of scheduled activities at the time of this inspection as the member of staff who had this responsibility had left the service. People told us they enjoyed singing and musical events. Bus trips took place regularly taking up to eight people out into the surrounding area.

The registered manager, a registered nurse, was supported by the clinical lead nurse. The registered manager chose to access support from a clinically trained member of the staff. There were senior care staff who supported the care staff team. All staff reported feeling well supported, settled and happy in their work. The service had benefited from a consistent management presence over the past six months.

We found beaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 you can see the action we have told the provider to take at the back of the full version of this report.

Before our inspection we reviewed all the information we held about the home. On the day we visited we spoke with five people who were living at St Margaret's. We also spoke with three relatives, three members of the care staff, two nurses and the acting manager.

We considered our inspection findings to answer our five questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them ad looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We judged the service to be safe on the day of our inspection.

People were treated with dignity and respect by staff.

Care plans were individualised and contained information that directed and informed staff to provide appropriate care and support.

There were enough staff to meet people's needs and a member of the management was available on call in case of emergencies.

Staff personnel records contained all the information required by the Health and Social Care Act. This meant the provider could demonstrate that the staff employed to work at the home were suitable and had the skills and experience needed to support the people living in the home.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints and concerns. This reduced the risks to people and helped to continually improve the service. St Margaret's alerted the local authority and the Care Quality Commission when notifiable events occurred or they had any concerns regarding people who used the service. St Margaret's held policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). We saw that they were using these protections appropriately.

CQC monitors the operation of the Deprivation of Liberty Safeguarding which applies in care homes. While no applications have needed to be submitted, appropriate policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

We reviewed the medication administration records (MAR). We did not see any gaps in these records. There was a medication policy and procedure for St Margaret's, which was in use. This helped to ensure people received their prescribed medication at the appropriate time.

Is the service effective?

We judged the service to be effective on the day of our inspection

During our inspection we observed staff caring for people. It was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people's needs.

People who lived at the service told us they sometimes had to wait to be taken to the toilet from the lounge areas. Staff confirmed this was an issue due to only having one toilet accessible with a hoist on the ground floor. The acting manager and lead nurse were aware of this concern and were working with the provider to address the issue.

Newly appointed staff received an induction prior to starting work, which included a period of shadowing more experienced staff.

Mandatory training was up to date and staff received further training specific to the needs of the people they supported.

We did not see any evidence of people being involved in their own care plan reviews. The acting manager told me they were about to starting using a document shared by the sister home, Trewiston Lodge, which would encourage the involvement of people and/or their representatives in their care plans and then ask them to sign in agreement with the contents.

Risk assessments were carried out to ensure people were protected from the risk of harm and guided staff on any action needed to minimise risk.

Is the service caring?

We judged the service to be caring on the day of our inspection.

Our observations of the care provided, discussions with staff and records we looked at enabled us to conclude that individual wishes regarding people's care and support were taken into account and respected.

From discussion with the staff, it was clear they understood the people's needs well. We were told the acting manager did their best to ensure the people were well cared for, and promoted people to have suitable opportunities and choices.

People's preferences, interests, aspirations and different needs had been recorded and care and support had been provided in accordance with people's wishes.

We saw visitors were welcomed throughout the day and encouraged to 'feel at home' during their visits, helping themselves to hot drinks from the kitchen. One visitor told us 'it feels like a real family here'.

Is the service responsive?

We judged the service was responsive on the day of our inspection.

From discussion with the staff and from inspection of records we judged there were suitable links with local health services. Records showed there was appropriate contact with medical professionals.

Recent residents meetings had led to the service changing its provision in accordance with people's wishes, for example, meal choices and activities available. We were told by one person that they greatly enjoyed the trips out in the community; we were shown a picture of a number of people who lived at St Margaret's enjoying a trip out to the zoo.

We saw people who lived at the home were supported to make choices, such as where they wanted to spend time and what they would like to eat. We saw catering staff asking people during the morning of our inspection what they would like to choose for their lunch that day.

We saw records of best interest meetings to decide individuals end of life care plans.

Is the service well led?

We judged the service to be well-led on the day of our inspection.

The staff told us that regular staff meetings were held. This showed the management consulted with staff regularly to gain their views and experiences and improve support for people who lived at the service.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and the quality assurance processes that were in place. They told us they felt able to approach the acting manager at any time and they were confident they would be listened to. This helped to ensure that people received a good quality service at all times.

Staff told us they were offered relevant and useful training on a regular basis.

The people we spoke with who lived at the service told us they found the acting manager was 'easy to talk to' and 'always there if you need anything'.

Regular audits were carried out to ensure the home was operating effectively and safely. Where these identified need for action this was followed up.

We spoke with the manager, the registered manager, a nurse, two carers and six people who lived at St Margarets Nursing Home. Overall people who used the service were positive about the home. Their comments included "I have no complaints" and "staff come when I need them".

We saw there was appropriate care planning documentation used in respect of people who lived at the home. People's care needs were assessed, care and treatment was planned and delivered in line with their individual care plan.

We found the home was warm and people told us, and we saw the bedrooms were in good decorative order and personalised with people's possessions.

We spoke to the registered manager, one member of staff, four people who used the service and two visitors to St Margarets Nursing Home. People told us "I have no compliants" and "they (staff) are all pretty good". People told us they felt able to approach the manager and staff if they had any concerns.

We found St Margarets nursing home had effective systems and processes in place to assist the management and staff in monitoring and reviewing the service that was provided.

Overall people were positive about the home and the staff, and told us the staff were 'very good' and 'lovely'. There were other comments including 'it can take a while for staff to take me to the toilet when I call', and 'Some of my clothes have not come back from the laundry'.

We found peoples' views and experiences had been taken into account in the way the service was provided and delivered in relation to their care.

Peoples' privacy and dignity was respected and people experienced care, treatment and support that met their needs and protected their rights.

People were protected from the risks of inadequate nutrition and dehydration.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

There were enough qualified, skilled and experienced staff to meet people's needs.

The provider did not have an effective system in place to identify, assess and manage risks to health, safety and welfare of people who used the service.

Records were stored securely in order to protect peoples' confidentiality.

Overall people were complementary about the staff, and told us they were 'kind'. However, other comments included, 'sometimes go a whole day without speaking to a sole', 'lack of social activity', and 'don't always get enough to drink'.

We found, people's privacy, dignity and independence were not respected and people's views and experiences were not taken into account in the way the service was provided and delivered in relation to their care.

People did not experience care, treatment and support that met their needs and protected their rights. Care and treatment was not planned and delivered in a way that was intended to ensure peoples safety and welfare.

People were not protected from the risks of inadequate nutrition and dehydration.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

There were not enough qualified, skilled and experienced staff to meet people's needs.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

Records were not kept securely.