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 the last assessment the service was in breach of the legal regulations in relation to people’s safe care and treatment; safeguarding; staffing and the premises. This key question was rated inadequate. This assessment found improvements had been made, and the provider was no longer in breach of the regulations. At this assessment the key question rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 demonstrate a proactive and positive approach to safety concerns, nor thoroughly assess for them. Furthermore, they did not investigate or report safety events appropriately.

Since the last assessment, the provider had developed a more proactive and positive culture of safety. There was a stronger emphasis on openness and honesty, and staff felt more confident to speak up when concerns arose. This supported a culture where learning was valued and safety was seen as everyone’s responsibility.

People and their relatives told us staff were continually learning as they supported them. One relative told us, “It is much better [at the service now].”

Staff listened to concerns about safety and took appropriate action when incidents or near misses occurred. Staff told us they discussed incidents and accidents so they could put measures in place to help prevent them from happening again. Managers reviewed incidents and looked for trends to see if changes were needed to improve people’s experiences. For example, they considered new equipment to help reduce risk and lessen the likelihood of repeated incidents. This helped ensure lessons were learned and contributed to embedding a stronger learning culture within the service.

At the last assessment, 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.

At this assessment, we found improvements had been made in how the provider supported people through safe systems of care and transitions between services. The provider now worked more effectively with people and healthcare partners to establish and maintain safe systems in which risks were monitored and managed appropriately. These improvements helped ensure people received consistent and coordinated care, including when they moved between different services.

Staff knew people well and were confident in the actions they needed to take if they noticed signs that someone required support from health professionals or specialist services. We saw many examples where staff had appropriately escalated health and wellbeing concerns, ensuring referrals were made promptly and people were seen by the right professionals at the right time. This meant people received the support they needed, when they needed it.

Continuity of care had also improved. Information sharing between staff, and with external services, was clearer and more reliable. This helped reduce delays, prevent gaps in care and supported smoother transitions when people needed additional assessments, treatment or changes in their care arrangements.

At the last assessment the provider did not have established and embedded systems and processes to help protect people from abuse. We found they did not share information and concerns quickly and correctly with appropriate agencies.

At this assessment, we found improvements had been made in the provider’s approach to safeguarding. The service now worked more closely with people and healthcare partners to understand what being safe meant to each individual and the best ways to achieve this. Staff focused on improving people’s day to‑today lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm. However, we did share with the provider where staff required further clarification on the external bodies they could contact in the event of concerns.

The provider now shared safeguarding concerns quickly and appropriately. This ensured potential risks were responded to without delay and that the right agencies were involved when needed. Records showed concerns were raised in line with local safeguarding procedures and actions were completed to reduce further risk.

Staff had completed safeguarding training, and up to‑to‑date information was available in the service on how to report concerns both internally and to external bodies, such as the local authority safeguarding team. Staff told us they were confident to raise concerns and felt able to speak freely with the management team.

Safeguarding issues were discussed with staff in meetings and supervisions to help improve their knowledge, strengthen approach and ensure learning was shared across the team.

We received positive feedback from people and their relatives. People told us they felt safe and well cared for, and their relatives told us they were happy with the way staff assisted their loved ones. For example, 1 relative said, “[Staff] show great love and care to [people].” Another relative told us, “I’ve never seen or heard anything untoward.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that the provider was able to identify when people were potentially being deprived of their liberty, complied with the basic principles of the Act, and made applications or/and urgent authorisations in a timely manner.

At the last assessment the provider had failed to 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.

At this assessment, we found improvements had been made in how the service involved people in managing risks. The staff now worked with people in a more holistic way, helping them understand their risks and supported them to make choices that were both safe and meaningful. Staff provided care that met people’s needs while also enabling them to do the things that mattered to them. We saw this approach embedded in people’s day-to-day support.

Since the last assessment, significant improvements had been made to care plans and risk assessments. These documents were now more detailed and offered clear guidance on how to reduce risks while still promoting people’s independence and choice. Staff were able to explain how they used this information to tailor their approach and ensure people were supported safely.

We found positive examples where people at risk of dehydration or poor health outcomes received effective monitoring and support. Staff understood the signs to look out for, and appropriate actions were taken to reduce risk. This helped ensure people received proactive and responsive care. One person and their relative told us staff knew which foods were safe for them to eat, and they kept to these foods. Another person and their relative told us the best thing about the service was, “[People] get well looked after.”

At the last assessment the provider did not always detect and control potential risks in the care environment. This meant equipment, facilities and technology did not always support the delivery of safe care.

At this assessment, we found many improvements had been made in how the provider ensured the environment was safe and further plans for environmental improvement were being considered. The service now detected and controlled potential risks within the care environment more effectively. Equipment, facilities and technology were maintained in a way that supported the delivery of safe and reliable care.

The provider had an ongoing action plan for maintenance and environmental improvements. We saw many areas of the home had already received remedial work, and further improvements were planned on a priority basis. Examples included a scheduled refurbishment of 1 bathroom and the planned replacement of an external door. These actions showed the provider was taking a structured and proactive approach to maintaining and improving the environment, and they should be completed as soon as practically possible.

We found improvements had been made to the environment, and ongoing environmental reviews took place. Staff completed routine health and safety checks, and the management team carried out audits to monitor the overall safety of the service. External contractors were used to maintain and oversee specific safety systems, which helped ensure the environment was safe.

At the last assessment we found the provider did not ensure there were enough qualified, skilled and experienced staff. Dependency assessments were not robust to allow for effective and safe staffing numbers to be considered. Staff did not receive appropriate guidance to provide safe care that met people’s individual care needs.

At this assessment, we found improvements had been made in how the provider ensured staffing was safe and suited to people’s needs. The provider now made sure there were enough qualified, skilled and experienced staff, and staff received appropriate support, supervision and opportunities for development. Teams worked well together and provided safe care that met people’s individual needs.

Dependency assessments were more detailed than at the last assessment. This gave clearer assurances around planned staffing numbers. We reviewed staff rotas and spoke with staff, and this confirmed staffing levels were planned and delivered in line with assessed needs. One staff member told us, “There is 100% enough staff!” Another staff member said, “It is relaxed and not rushed here, so we are given the time we need to allow people to do as much as they can [for] themselves.” People told us there were enough staff available to support them.

Training provision had also improved. We found staff had completed the training needed to carry out their roles safely and effectively. A combination of face-to-face sessions and eLearning was used, and competency checks or practical assessments were completed when required to ensure staff were confident and capable.

The provider demonstrated they were now planning training more effectively, ensuring staff attendance and maintaining oversight of learning needs. They also had further plans to introduce professionally recognised training for staff during 2026.

At the last assessment the provider had not responded effectively to reduce infection control risks.

During this assessment, we found improvements had been made to infection prevention and control (IPC). The provider now assessed and mostly managed infection risks effectively. They took account of people’s needs and kept ongoing environmental improvement plans under review. General IPC audits and checks had improved, and actions were taken or planned when needed.

Staff were observed wearing PPE, and this was used appropriately throughout the service. Domestic staff told us they had all the cleaning materials and equipment they needed to keep the home clean and maintain good hygiene standards. They said, “I have no problems asking for [items]. Anything I need, equipment or materials wise, I get [without delay].”

However, there was still room for improvement in ensuring work was carried out promptly to reduce avoidable risks. An external health professional completed an IPC review in August 2025 and identified a specific piece of equipment required renewal work for infection control purposes. We found this issue remained unresolved during our assessment visits in December 2025. The provider told us the renewal was scheduled for January 2026, but the delay meant the risk continued for several months. We also noted further decoration work was needed to ensure surfaces could be easily cleaned.

We recommend the provider review their agreements and arrangements with external contractors to ensure renewals are completed in a timely manner. This will help ensure any identified IPC risks are addressed quickly and consistently.

Overall, while progress has been made, some further improvements are still required to ensure infection prevention and control is managed in a timely, safe and effective way.

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

Since the last assessment, we found improvements had been made in how the provider managed and oversaw medicines. Systems were safer, staff demonstrated improved knowledge, and audits and competency checks were completed effectively. Staff administered medicines safely, followed correct procedures, and had a clear understanding of their responsibilities.

However, some improvements were still needed. We found that 1 person’s medicine record was not clear enough to ensure their medicines were given safely. Staff told us the prescriber had recently changed the instructions, and staff took action to update the record, so it matched the new prescription. We also saw that staff used codes on the medicines administration record to document when a medicine had not been given, but there was no key to explain what those codes meant. Although no one was harmed, these issues showed the provider still needs to strengthen their processes.

During the assessment, we observed the provider was responsive to feedback and took immediate action to further improve safety. For example, when we highlighted the need for more robust temperature monitoring to ensure medicines were stored within safe parameters, the provider promptly reviewed the equipment in use. A new, more accurate thermometer was purchased and put into use without delay. The provider also obtained a safe and appropriate piece of equipment to accurately count loose medicines. This supported safer administration and improved safety and accuracy in medicine stock checks.

The provider demonstrated ongoing commitment to learning and improvement through regular audits and competency assessments of staff. These checks were used effectively to maintain oversight and safety.

While good progress had been made, further development is needed to ensure prescribers’ instructions are always fully clarified and recorded, and all systems consistently meet the standards required for safe medicines optimisation.

People told us they were happy with how staff supported them with medicines administration and relatives, where appropriate, were kept up to date with any changes. For example, 1 relative told us, “We’re kept informed of any changes to [medicines]. And we are asked for consent for any [vaccinations].”