St Margarets Nursing Home

On this page

• 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.

Governance systems were ineffective, some records were disorganised, and audits had failed to ensure compliance with the regulations. The service culture was not entirely focused on supporting people and necessary notifications had not been submitted.

The provider responded positively to feedback provided and immediately began introducing change to address issues and improve performance. Staff spoke favourably of the registered manager and a clinical lead had recently been appointed to give leadership and support to the staff team.

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

This service scored 61 (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. They did not always understand the challenges and the needs of people and their communities.

The culture of the staff team was not entirely focused on ensuring people’s needs were promptly met. Staff enjoyed spending time together and routinely ate lunch as a group. People reported incidents where staff had failed to respond to their requests. They indicated this was a particular issue at weekends when management oversight was reduced.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us the registered manager was approachable and supportive. Their comments included, “The registered manager is so supportive, not just in work but life as well, always there for a shoulder to cry on. They do support you very well” and “The managers are brilliant. I find them very supportive. If you have a problem you can go to them and you will get help”. People were also complementary of the registered manager and told us, “[The registered manager] is lovely, [they] know what [they] are doing”.

The registered manager told us they were well supported by the provider and the nominated individual was present during both inspection days to offer assistance. The provider had recognised additional clinical leadership was required prior to the inspection and a clinical lead nurse had been appointed to support the registered manager.

The registered manager was open with the staff team and had promptly shared feedback following our initial site visit to identify areas of possible improvement. The registered manager was confident the staff team had the skills necessary to meet people’s needs and told us, “Everyone has stepped up”.

By the second day of the inspection, works were underway to replace areas of flooring, activities plans had been developed, and staff tasked to review and update people’s care plans. This demonstrated the provider’s focus and willingness to make the changes necessary to improve performance.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Managers and staff encouraged feedback from people and visiting relatives and shared information quickly when people’s needs changed. Relatives told us, “Managers are always very friendly and always there to talk to” and “There was a little bit of a problem, we spoke to them and it has been resolved”.

Staff meetings were held regularly. Information and details of the concerns identified during the inspection process were shared openly with the staff team. This helped empower staff to make the changes necessary to improve performance.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff consistently told us they were treated fairly by their managers, who were supportive and compassionate. One staff member said, “I had a car accident and had to have a week off, I could not have asked for a better manager through it”. Another staff member told us, “I love the registered manager, if anything’s wrong I can go to [them for help]. Kept in touch and offered support right through [a period of absence]”.

Requests for reasonable adjustments to working practices had been looked on favorably and one staff member told us, “I can start at 9 as I don’t have anyone to take [my children] to school”.

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

The provider’s governance systems were ineffective and had failed to ensure compliance with the requirement of the regulations. Care plans did not accurately reflect people’s current needs. Risks known to staff had not been documented and mitigated. Records in relation to people’s mental capacity and associated Deprivation of Liberty Safeguards (DoLS) applications were disorganised. Staff and managers were unable to locate these records when requested and there were no effective systems for monitoring DoLS applications.

The registered manager did not have procedures to monitor staff performance and to ensure tasks delegated to clinical staff had been completed. Staff had not received regular supervision as required by the provider’s policies. Clinical staff’s competency to support people with medicines had not been regularly reviewed.

Auditing systems were not robust. Environmental and safety audits had failed to identify unrestricted widows and that some radiators were uncovered. In addition, necessary notifications had not been submitted to the commission when required.

However, the provider responded positively to feedback from this assessment and the local authority. A clinical lead had been recently appointed to support the registered manager and provide additional leadership and support to the nursing staff. Prompt arrangements were made to service lifting equipment following feedback from the local authority and all hoists had been serviced prior to our inspection. Following comments about the safety of flooring made during the first day of the inspection, action was taken and the damaged flooring was being replaced during the second site visit. During our second site visits work was underway to review and update people’s care plans.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service engaged positively with health partners to ensure people’s needs and expectations were met. There was open and routine communication with the GP practice and visiting district nursing teams to ensure people needs were recognised and addressed. The provider worked flexibly with partners to ensure missed nursing visits did not impact on people’s wellbeing.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider did not have effective systems to ensure learning was identified from any incidents or accidents that occurred. The registered manager did not have robust procedures for monitoring staff performance to ensure allocated tasks had been completed. Planned formal supervision meetings had not taken place. This meant opportunities for learning or sharing concerns had been missed.