St Margarets Care Home

On this page

• 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

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment; safeguarding; staffing; and the premises.

This service scored 25 (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 proactive and positive approach to safety. They did not recognise safety concerns, nor thoroughly assess for them. This meant they also did not investigate or report safety events appropriately. Lessons were not learnt to continually identify and embed good practice.

National patient safety alerts had been widely shared regarding the risk of asphyxiation to people who may incorrectly ingest thickening powder. Thickening powder is used to make drinks a safe consistency for people who have swallowing difficulties. We found people were at risk of asphyxiation due to 1 person’s thickening powder being left unattended and accessible.

The provider failed to learn from other previous safety concerns. During our assessment we found the Local Authority had raised some specific matters with the provider which included concerns in relation to the environment, medicines management, appropriate care planning and risk assessment and the legal consent processes. During our assessment we found these issues remained present and had been repeated. We did not find a safe and effective learning culture was present at the care home.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The provider did not appropriately act upon people’s changing needs, to demonstrate safe systems of care and ensure the management and monitoring of people’s safety. During our assessment 1 person required increased staff support with orientation and safe mobilising. On occasions the CQC inspectors had to intervene to ensure the safety of the person, as staff were not present, and the person was at high risk of falls. Staff told us 1 member of staff would visually monitor the person; however, we found this was not the case all of the time.

The provider had not effectively considered what was in the person’s best interests and delays in assessments for a more suitable care provider were apparent. We found concerns had been raised previously by social care professionals and were not thoroughly recognised and acted upon by the provider. During our assessment timeframe the person’s needs were reassessed and they did transition to another provider.

The provider did not have established and embedded systems and processes to help protect people from abuse. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share information and concerns quickly and appropriately with appropriate agencies.

The provider had failed to recognise and report safeguarding concerns without delay. The Local Authority had found the provider had not responded correctly to unexplained bruising and falls. Furthermore, they found the provider was not effectively monitoring Deprivation of Liberty authorisations robustly, and an authorisation had expired for 1 person. This meant an established, embedded and safe culture could not be demonstrated during this assessment and people had been at risk of receiving care and treatment without lawful authority. Furthermore, the Local Authority had identified knowledge gaps for both the provider, and staff, which we found were still present during this assessment.

The provider did not demonstrate a commitment and clear understanding of the importance of involving people, or their representatives if more appropriate, with specific considerations surrounding monitoring equipment. For example, we found surveillance devices in use on some bedroom doors. These had not been recognised as surveillance and restrictive measures by the provider, and clear decision and best interest processes had not been undertaken nor recorded.

The provider further failed to implement and demonstrate a culture where people were protected from improper treatment. Staff told us they used a digital cross platform messaging service for work communications, this sometimes-included photographs of service users’, and monitoring photos of their skin condition. The provider and staff failed to recognise this meant all staff within the group had access to the photographs shared, and safe procedures had not been followed. We informed the Local Authority of our concerns regarding this.

The provider did not maintain full oversight records relating safeguarding. We found where outcomes of safeguarding referrals had been received from the Local Authority, these were not added to the safeguarding records at the care home. Furthermore, the provider did not have a specific monitoring tool for accidents and incidents, this meant oversight and safety monitoring was not safe or effective. There were no specific reviews completed which would monitor for trends or frequencies of incidents to help mitigate the risk of future recurrence. The provider did have a falls log; however, we found this lacked sufficient detail to evidence clear oversight.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider failed to recognise, correctly assess and act upon risks to individual people. This meant people were at risk of avoidable harm. For example, appropriate smoking risk assessments had not taken place, and this meant people were not supported safely to do the things that mattered to them. We also found this had then placed other people at risk of harm. We requested an effective review be completed during our assessment timeframe, and a CQC inspector needed to support the provider, and their staff, with risk identification and potential risk reducing measures to ensure this was done safely.

During our assessment, the local fire inspector completed a review of the care home, which had been requested by the Local Authority. They found staff had not been given opportunity to practice emergency evacuation procedures, which meant the provider could not be assured of safe practice. This had placed people at risk of harm in the event of a fire. This training was later organised and provided to staff by the fire inspector.

The provider failed to ensure appropriate risk assessments were in place to help people maintain and improve the condition of their skin. We found risk assessments were not completed correctly to classify risk, and this meant risk reducing measures were not identified for appropriate implementation.

We found other risks to people had not been assessed, and guidance was not available for staff. For example, 1 person had epilepsy, and there was no care plan, risk assessment or protocol in place for staff to refer to. We reviewed 2 people who were at risk of choking and needed a modified diet to promote safe swallowing. The provider had not completed a care plan or risk assessment in response to this.

People were at risk of dehydration and poor outcomes due to ineffective monitoring. Food and fluid recordings were not appropriately completed or reviewed. This meant responsive action was not evidenced for low recordings.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

People were not supported to be safe in the environment and we found a poor safety culture was present. We found high risk areas, such as the kitchen, laundry and domestic room unlocked and accessible. We observed people enter the kitchen when staff were not present, when it was not safe for them to do so. We raised our concerns on multiple occasions with the provider during our first visit, however, we continually found the rooms unlocked and accessible. We asked the provider to immediately address this concern during our assessment, and more suitable locks were arranged by the provider during our second visit.

The provider had not ensured safe environmental work had been completed. The Local Authority had raised concerns with the provider regarding some fire doors discharging without warning from their holding mechanism. We found this had not been addressed by the provider, and risk was present to people. Furthermore, due to the door mechanisms not working correctly, we found some doors were inappropriately held open. This had left people at risk of harm if the doors were not closed in the event of a fire.

The provider failed to ensure people had access to ample wash facilities. At the time of our assessment only 1 shower was working, for 15 people. There were 2 baths at the care home, however, staff told us the lifting equipment in 1 bathroom was not operational, and the other bath did not have lifting equipment and so was not used.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. Staff did not receive appropriate guidance to provide safe care that met people’s individual needs.

Safe staffing levels were not robustly assessed or reviewed which placed people at risk of harm. There was not always enough staff to meet people’s needs. The provider told us they determined safe staffing levels using dependency assessments; however, these did not consider the specific support needs of people, their associated time requirements and the layout of the care home. For example, we found only 1 staff member was on duty between the time of 21.30 and 22.00 for 15 people. The provider had failed to recognise the risk associated with this and told us this had always been their staffing arrangement. People had varying needs, which included requiring support from 2 staff.

Staff told us staffing levels were not always sufficient. For example, 1 staff member said, “We could do with a few more [staff]. It is safe but we need more time when things are busier and would be good to spend some more time with people”. We observed staff were not deployed safely at the care home. There were periods of time where staff were not present in the communal areas, and people in their bedrooms did not receive timely support when they required staff, appeared distressed or were at risk of being isolated.

The provider failed to ensure staff had completed safe and effective training. We found staff had not completed training to meet the specific needs of people they supported, for example, epilepsy and diabetes training had not been undertaken. Furthermore, not all staff had completed training in end-of-life care, and we found shortfalls in this provision to people.

The provider did not assess or manage the risk of infection appropriately. They did not safely consider the needs of people, and the environment.

We were not assured the provider had responded effectively to reduce infection control risks. The environment required redecoration, we found chips in woodwork and paintwork, which meant these surfaces could not be appropriately cleaned. The Local Authority had assisted the provider to implement an environment action plan following their visit. This included flooring replacement and specific cleaning and monitoring requirements. The provider had not completed this review themselves for the ongoing safety and suitability of the environment or understood the infection control risk this presented.

The provider did not recognise the importance of planned infection prevention and control. On 2 of our visits a domestic was not on duty, they had planned leave and sufficient arrangements to cover this role, and duties had not been made.

We were not assured the provider was using Personal Protective Equipment (PPE) effectively and safely. Staff did not always recognise the need for effective hand washing and safe use of PPE. We observed 1 staff member complete medicines administration for people whilst wearing the same pair of disposable gloves, and no washing of hands took place. This had placed people at risk of cross infection.

The provider did not make sure that medicines and treatments were safe and met people’s needs. The provider did not ensure medicines were administered safely.

We observed a staff member administering medicines without looking at the medicine administration records. This meant staff did not always refer to the prescribed instructions and this placed people at risk of harm. Despite this concern, the provider did not complete a supervision or medicines competency assessment with the staff member immediately following this incident.

The provider did not demonstrate people were being given their medicines as prescribed as staff were not following the correct administration times. For example, 7 people were prescribed medicines to be taken 30 – 60 minutes before food. Staff did not follow this direction and told us they were unaware; however, we found this prescribed direction was printed on the medicine administration record. Furthermore, 1 person had been prescribed a short course of medicine, and we found although 8 doses were prescribed, staff had signed to indicate 13 had been administered. The provider had not identified this concern, and was unable to explain how this medicine had been administered.

Medicine checks were not robust to ensure medicines management was safe. We found medicines audits were not structured, and they did not review all medicines prescribed. Furthermore, recorded medicine balances did not reflect the amount of medicine available, and medicine was not always checked to have been administered from the packets. We were not confident people received their medicines as prescribed.

The provider did not ensure medicine expiry dates were regularly reviewed. We found expired medicine at the location, which meant these would not have been safe to administer. The provider’s own audit systems had not identified this concern.

The Local Authority had undertaken a medicines review at the care home in 2024. They also found expired medicine, and medicines which had not been dispensed appropriately from their packets. Our assessment found these same safety concerns which meant the provider had not made sure appropriate actions had been taken.