- Care home
St Margarets Care Home
Assessment report published 24 July 2025
Contents
Ratings
Our view of the service
Date of assessment: 15 April 2025 to 29 April 2025. We visited the care home on 15 April 2025, 17 April 2025, 23 April 2025 and 29 April 2025. This unannounced assessment was carried out as we received concerns relating to safe care and treatment.
St Margarets Care Home is a care home without nursing that is registered to provide services to up to 16 older people, some of whom may live with dementia. Accommodation is provided across 3 floors, with stair lifts available for access. There were 15 people living at the home at the time of this assessment.
The service had a manager registered with the Care Quality Commission (CQC). The registered manager is the provider of St Margarets Care Home and will be referred to as ‘the provider’ throughout this report. The provider is legally responsible for how the service is run and for the quality and safety of the care provided.
At this assessment we identified 8 breaches of legal regulations which related to safe care and treatment, safeguarding, staffing, person-centred care, consent, dignity and respect, the environment and good governance.
We were not assured people were receiving safe care and treatment. Medicines were not being managed safely or administered as prescribed. We found significant shortfalls in the care planning and risk assessment process at the care home. People’s care plans were not updated when their needs changed, nor were they a holistic reflection of people’s needs and wishes.
Mental capacity processes required significant review, and we were not assured the training completed by staff was sufficient. Rigorous safeguarding processes were not evident, and the provider failed to ensure referrals and notifications, where required, had been completed and sent to the relevant external bodies. The premises required decorative and refurbishment work, and we found high risk areas were not always secure to promote safety. The provider failed to act upon concerns raised by the Local Authority in a timely way, which led to further concerns and risk.
Safe staffing levels had not been robustly assessed, and we found staffing levels were not always sufficient. The provider told us staffing numbers had always been the same, which did not evidence safe staffing levels were reviewed based upon people’s needs and any specific risk present. We found improvements were required to ensure people received care, which was dignified, respectful and person-centred. The provider did not have oversight of the service to monitor quality and safety appropriately. Furthermore, we found shortfalls in their regulatory knowledge to drive improvements and meet the required regulations.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and / or appeals have been concluded.
This assessment was carried out by 2 inspectors and 1 Expert by Experience. An Expert by Experience is a person who has had personal experience of using or caring for someone who uses this type of care service. We sought feedback from health and social care professionals who worked with the service.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
People's experience of this service
We spoke with 15 people. 9 people who used the service, and 6 people’s representatives, to gather information about their experiences. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.
People, and their representatives, told us they were generally happy with the care provided at St Margarets Care Home. However, some people told us there could be delays when they used their call bell or wanted support with personal care. Furthermore, people and their representatives were not always kept up to date when referrals to healthcare professionals had been made.
People, and their representatives, were happy with the food provided at the care home, for example, 1 person told us, “The food is good, there’s usually something I like”. Another person told us, “We get a choice of 2 mains, if I don’t like either there are alternatives”. Representatives told us despite the dated appearance of the service, both internally and externally, they saw past this due to the quality-of-care people received. All representatives told us they were happy with all aspects of the service, including staffing, care, food and management.
Whilst people and their representatives expressed satisfaction with the care, and service provided, our assessment found it did not meet the expected standards.