St Margarets Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At the last assessment the service was in breach of the legal regulation in relation to person-centred care. This key question was rated inadequate. This assessment found improvements had been made and the provider was no longer in breach of the regulation. At this assessment the key question rating has changed to good. This meant people’s needs were met through good organisation and delivery.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the last assessment the provider did not make sure people were at the centre of their care and treatment choices. The provider did not work in partnership with people, or their relatives if appropriate, to decide how to respond to any relevant changes in people’s needs.

The provider had made improvements since the last assessment to ensure care was person‑centred. Care plans were accurate, detailed, and reflective of each person’s needs. Staff and managers demonstrated a better understanding of care planning being an ongoing process, not a one-off task. We saw timed reviews took place as expected, but also care plans were updated sooner when people’s needs changed. This meant information remained current and staff had clear guidance on how best to support people.

People, and their relatives where appropriate, were actively involved in developing and reviewing care plans. Regular communication took place, and people told us they felt listened to and included. Relatives said they were kept informed and appreciated being asked for their input, especially when people were unable to share their views independently. This open communication helped ensure care remained aligned with each person’s wishes, routines, and preferences.

Another improvement was the involvement of a wider range of staff in the care planning process. This meant plans were more comprehensive, as they reflected insights from those who knew people best and supported them day‑to‑day. Staff were confident in describing people’s needs and how to meet them, and they understood the importance of personalising care and promoting choice.

At the last assessment there were shortfalls in how the provider understood the diverse health and care needs of people and their local communities.

Although improvements had been made, we found some further work was still required to ensure documentation consistently supported safe and coordinated care. Day-to-day records did not always clearly document when people had been assessed by emergency services and follow up information was sometimes missing when a person had spent time away from the service. This reduced oversight and did not always give staff or managers a complete picture of events affecting people’s health and wellbeing.

Despite this, the provider had made noticeable improvements in other aspects of care provision and continuity. Care for people living with dementia had strengthened since the last assessment. Staff had developed a better understanding of how dementia could affect communication and daily routines. Staff had adapted their approach to ensure care and activities were more appropriate, reassuring and meaningful. People were supported in ways that promoted comfort, familiarity and engagement.

Staff communication had also improved to meet the diverse communication and health needs of people. Staff used a variety of approaches including clear spoken language, visual prompts and calm, patient explanations to help people understand what was happening and to support them to express their choices. This helped reduce confusion and improved people’s experience of day‑to‑day care.

We found staff had a good understanding of the health conditions which affected the people they supported. They described how specific conditions influenced mobility, mood, and decision making, and were able to explain how they adapted their practice accordingly. As a result, care was more consistent, better coordinated and more responsive to people’s changing needs.

At the last assessment the provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

At this assessment, the provider had made noticeable improvements in how information was shared with people, their relatives and staff. During this assessment, we saw information was provided in clearer and more accessible formats, helping people better understand their choices and daily routines.

At mealtimes, people who benefitted from visual support were offered pictorial cards showing the different food options available. This helped people living with dementia, communication difficulties or impaired vision to make informed choices and feel more involved. Staff used these cards sensitively and checked with people to ensure their preferences were understood.

Improvements had also been made in how the provider gathered and reviewed feedback. The provider had introduced a more structured approach to collecting views from people, relatives, visiting professionals and staff. They could demonstrate how this feedback was formally reviewed, what actions were taken as a result, and how follow up‑up reviews were planned to check whether changes had been effective.

At the last assessment the provider had not made it easy for people to share feedback and ideas or raise complaints about their care. Staff had not involved people in decisions about their care.

At this assessment the provider had made positive improvements in how they listened to and involved people in their care. Staff communication had improved, and we saw staff actively seeking people’s consent before offering care and support. They used clear, respectful language and ensured people had time to consider their choices. This helped people feel more in control and promoted meaningful involvement in their daily routines.

People were offered choices throughout the day, and staff took care to explain options in ways that suited each person’s communication needs. This approach supported people to express their preferences and helped staff tailor care more closely to individual needs.

The provider had also strengthened how they engaged with people and their relatives. Regular meetings were organised to share updates about the service, discuss any planned changes, and seek views on matters that were important to them.

A complaints policy was available, and records showed the provider acted upon concerns, comments and complaints appropriately. Responses were timely, clear, and demonstrated a commitment to resolving issues and learning from feedback. People and relatives said they felt comfortable raising concerns and confident that they would be listened to. For example, 1 person’s relative told us, “I know about the complaints process, but if there was anything I didn’t like, [staff] would know.”

At the last assessment the provider did not always make sure people had equity in access.

At this assessment, the provider had made improvements to ensure people had fair and appropriate access to the care, support and external services they needed. Care plans were improved and contained clearer, more accurate information about people’s health needs, preferences and risks. This helped reduce the likelihood of people receiving inappropriate or inconsistent care, and supported staff to provide care that was safe, proportionate and responsive.

People were able to see healthcare professionals, such as their GP and community nurses, when they needed to. Staff told us they had good relationships with local health teams, who were supportive and carried out reviews or visits as required. Records showed health referrals were made in a timely way and follow up actions were completed.

The provider had arrangements in place to ensure people could access a range of additional services to support their wellbeing. This included agreements with professionals such as a hairdresser, chiropodist, dentist and optician to visit the care home when needed. These visits helped people maintain their health, comfort and dignity without facing unnecessary barriers.

At the last assessment we found leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

At this assessment the provider had made improvements to ensure people experienced fair, personalised and positive outcomes. People and their relatives were more actively involved in the care planning process, and their views were listened to and used to shape care. This meant care plans were more reflective of people’s individual needs, preferences and what mattered to them.

People told us they felt consulted, and staff were more consistent in seeking people’s feedback about their day-to-day experiences. This contributed to care which was better tailored and more aligned with each person’s wishes.

We saw improvements in the range and quality of activities offered. People were involved in purposeful activities they enjoyed which supported both mental and physical wellbeing. These opportunities helped people stay engaged, stimulated and connected, and contributed to more positive experiences.

At the last assessment we found people were not supported to plan for important life changes. We found the provider did not ensure prompt care and treatment reviews took place for people, and this had meant important opportunities to discuss the future did not take place.

At this assessment, the provider had made improvements in how they supported people to plan for the future. Staff and managers recognised the importance of giving people and their relatives regular opportunities to talk about what mattered to them. This helped ensure future planning was based on people’s wishes, preferences and individual priorities.

We saw conversations about future needs, choices and preferences were taking place more consistently. People and their relatives were encouraged to share what was important to them, such as preferred routines, cultural or religious beliefs, personal goals, and how they wished to be supported if their needs changed. This information was recorded more clearly and used to guide ongoing care planning.