St Margarets Care 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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 32 (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 culture based on transparency, equality and human rights, diversity and inclusion, and effective engagement was not evident. Leaders and staff did not understand the challenges and the needs of people and their communities.

The provider failed to implement policies and procedures which meant the aims and objectives of the service were not correctly implemented and embedded. At the time of our assessment staff did not have access to the providers policies and procedures and very few had been shared with them. There was a lack of effective oversight and leadership at the care home which meant people were not supported appropriately or engaged in a meaningful way.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leaders did not have the required skill and knowledge to deliver a safe and effective service. During this assessment we found multiple breaches of regulation. These widespread failings did not demonstrate the provider had safe and effective oversight of the service provided to people, nor did it demonstrate to us an understanding of regulatory requirements for the safe care of people.

The provider had not implemented the freedom to speak up policy. This meant staff had not been informed as to how to speak up, or the process to follow if they were not happy. However, staff did tell us they felt able to speak to the provider about concerns they had. The provider had not sought feedback from staff, for example, through a staff survey or using an online anonymous questionnaire to allow their views to be shared freely.

The provider missed valuable opportunities for feedback, especially as an anonymous feedback opportunity was not available for staff. For example, 1 member of staff told us staffing levels were not always sufficient. This meant there were areas for the provider to work on to ensure feedback could be shared freely by staff, when required.

During our assessment, the provider told us they planned to implement the freedom to speak up policy and discuss some specific training and roles with staff for this important provision.

The provider did not always work towards an inclusive and fair culture by improving equality and equality for all staff who worked for them.

The provider employed a diverse staff team, including different ethnic backgrounds and genders.

There was evidence of staff meetings and individual supervisions to show staff were included in some decision making. However, improvements were required to ensure equity in how information was shared with staff.

We found staff worked differing shift patterns, sometimes shift times were mismatched, and this meant effective handovers, information sharing and policy and procedure implementation was not evidenced or effective.

During our assessment the provider did implement a staff communication book at the care home to improve information sharing and inclusion.

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 failed to identify and implement safe systems and processes to operate effectively. This included systems to assess, monitor and mitigate the risks to people’s health, safety and welfare. The provider had also failed to act promptly when concerns relating to the environment were shared by health and social care professionals. The providers governance systems were inadequate at the time of our assessment and offered no assurance of oversight.

The provider told us they were taking action to address concerns following our assessment findings and the feedback they had received from the Local Authority. The provider said they recognised the areas which required improvement and told us they were committed to making these changes.

The concerns we found during this assessment had not been identified by the provider, and this was reflective of the culture at the service. The provider had relied on external agencies, such as the Local Authority, and the Commission, to identify shortfalls and areas for improvement. Governance systems were not robust, and did not identify concerns nor drive improvements. We found failures and breaches in regulation in many areas, which included medicines management; appropriate risk identification and actions; care planning; safeguarding processes; staffing and end of life care. The providers processes were not robust, and people had been placed at risk of receiving care which did not meet their needs.

The provider did not understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

We found the lack of effective oversight, leadership and monitoring at the care home impacted collaborative working and sharing of information. Learning and quality improvement was not an ongoing process. People’s care plans were not detailed, person-centred or accurate, and effective partnership working with people, their representatives or external health professionals was therefore not demonstrated.

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

We found the provider had a reactive approach to running the service. They responded to issues raised by the Local Authority, Fire Service and CQC. For example, following the fire inspector visit, they ensured staff attended fire evacuation training, however, this was organised and led by the fire inspector. When we raised concerns about high-risk areas, actions were not thoroughly taken and implemented until we said immediate actions were required. The provider was not proactive in identifying areas for improvement and we were not assured the service could improve without support.

The provider did organise for an external consultant to work with them at the care home, and we met them on our final assessment visit. The provider, and external consultant, identified the areas of priority for work to commence. This included working with people and staff to drive improvements. The provider was aware of their need to learn, sustain and embed any new governance and oversight systems and tools, to ensure they are used and managed effectively to promote safe care.