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 the last assessment the service was in breach of the legal regulation in relation to governance. 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 the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 we found 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 had failed to implement policies and procedures which meant the aims and objectives of the service were not implemented or embedded.

Since the last assessment, the provider had made improvements in developing a shared direction and a positive culture. Leaders and staff worked in a way that reflected the values of transparency, equity, equality, human rights, diversity and inclusion. These principles were evident in day-to‑day practice and helped create an environment where people felt respected, listened to and valued.

The provider had implemented their policies and procedures. Staff understood these, and we found the aims and objectives of the service were now clearly embedded in everyday work. This stronger, shared understanding meant staff were more consistent in their approach and able to provide support in a more meaningful and person‑centred way. People and relatives told us communication felt more open, and they felt more confident in the leadership of the service.

At the last assessment we found the provider did not have capable, compassionate and inclusive leaders. We found leaders did not have the required skill and knowledge to deliver a safe and effective service.

The provider had made improvements in leadership since the last assessment. The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support. They demonstrated a strong awareness of the needs of their workforce and the people using the service, and they expressed the organisation’s values in their day‑to‑day practice. The provider had a new trainee manager in post, and positive feedback was received regarding their practice.

Leaders were visible within the service and approached their roles with integrity, openness and honesty. Staff told us they felt supported by leaders and appreciated the clear direction and positive example they set. For example, 1 staff member told us, “I am well supported in that I always get a response - not once have [management] not got back to me.” Another staff member said, “[Managers] are really listening now, and it is much better than when [inspectors] were last here.” A third staff member said, “The managers support me and everyone. Everything is different, and everything is good.”

Action had been taken to address the concerns raised at the last assessment, and the provider was no longer in breach of regulations. Leaders showed a commitment to learning and improvement, and they took responsibility for making the necessary changes. This included strengthening their oversight of the service and improving systems for monitoring quality and safety.

The provider demonstrated a greater understanding of regulatory requirements and what is needed to deliver safe, effective care. This improved oversight meant issues were recognised more promptly, and appropriate action was taken to help prevent them from re‑occurring.

At the last assessment the provider had not implemented their 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.

At this assessment we found the provider had made improvements in how the service supported staff to speak up. The leadership team had fostered a more positive and open culture where individuals felt confident raising concerns, knowing their voice would be heard and taken seriously. Staff told us they felt safe and supported to report issues, and they were reassured concerns would be handled fairly.

The provider had implemented a Freedom to Speak Up policy, which clearly outlined how concerns could be raised and what actions would follow. A named staff member had taken on the role of ‘Freedom to Speak Up Champion’, providing an accessible point of contact for staff who wished to discuss issues confidentially or needed guidance. This helped strengthen trust and accountability within the service.

At the last assessment we found the provider did not always work towards an inclusive and fair culture by improving equality for all staff who worked for them.

At this assessment, we found improvements had been made in how the provider promoted equality, diversity and inclusion within the workforce. The provider valued the diversity of their staff team and recognised the strengths that different backgrounds, experiences and perspectives brought to the service.

Leaders had taken steps to build a more inclusive and fair culture by improving equality for staff. Staff told us they felt respected and supported, and they described a fair and supportive workplace. This contributed to a more positive working environment and strengthened staff morale.

The provider had also improved how information was shared with staff. Communication was more consistent and clearer than at the last assessment. Effective staff meetings and handovers were taking place, which ensured important information was shared promptly and accurately. This supported better continuity of care and helped staff feel informed, included and confident in their roles.

At the last assessment we found 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.

At this assessment, we found improvements had been made. The provider had implemented safe systems and processes which helped the service to operate more effectively. These changes strengthened oversight and ensured issues were identified and addressed promptly. Records showed leaders used audits, checks and feedback to continually monitor the quality and safety of the service.

The provider had taken appropriate action in response to the concerns found at the last assessment, as well as feedback received from the local authority. At the previous assessment, the provider told us they were committed to making improvements, and at this assessment we found improvements had been made, embedded and maintained over time. The provider demonstrated an ongoing improvement plan which was being completed on a priority basis.

At the last assessment the provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

At this assessment, we found improvements had been made. The provider and staff team worked with partners and engaged with the wider community. Oversight, leadership and monitoring had strengthened, which helped support more consistent and coordinated partnership working.

Collaborative working and information sharing had improved. Staff communicated more effectively with visiting health and social care professionals, and the feedback we received from these professionals confirmed joint working had become more positive. They told us staff were more prepared, more responsive, and more confident in sharing relevant information about people’s needs.

Improvements to people’s care plans also supported stronger partnership working. Care plans were more accurate, up to date and reflective of people’s current health and support needs. This meant external professionals had clearer information when visiting, and staff were better able to work alongside them to deliver consistent care.

At the last assessment we found the provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They had not encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They had not actively contributed to safe, effective practice and research.

Since the last assessment improvements had been made. The provider had become more proactive in their approach to running the service. They demonstrated a stronger commitment to learning from feedback, understanding areas for development and taking action to make meaningful improvements.

The provider had strengthened their governance and oversight arrangements by using the services of an external consultant. This support helped them identify gaps, introduce appropriate systems, and embed tools that promoted safer and more effective care. As a result, oversight was more robust and leaders were better able to monitor quality, address risks and sustain improvements over time.

We also found the provider worked with visiting healthcare professionals to improve their service. Staff were more open to professional feedback and used the advice given to adapt and refine their practice. This collaborative approach helped ensure care was more responsive to people’s needs and aligned with recognised best practice.