Margaret's Rest Home

Updated 17 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was carried out by 1 inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Margaret’s Rest Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Margaret’s Rest Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a new registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. This included the action plan the provider sent to us after the last inspection to show what they would do and by when to improve. We sought feedback from the local authority. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 6 people who use the service. We spoke with a visiting health professional. We also spoke 10 staff. They included the registered manager, deputy manager, senior carer, care staff, cook, activity staff, house-keeping staff and maintenance staff. We also spoke with the nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed a range of records. This included 10 people’s care records, multiple medication records and 3 staff files in relation to recruitment and supervision. A variety of records relating to the management of the service, including staff training information, audits, meeting records policies and procedures.

After the inspection visit we telephoned 2 relatives to gather their views about the quality of care.

Updated 17 June 2023

About the service

Margaret's Rest Home is a residential care home providing accommodation and personal care for up to 27 people. The service provides support to older and younger people, people living with dementia and people with physical disabilities. At the time of our inspection there were 26 people using the service.

People’s experience of using this service and what we found

People and their relatives felt the service was safe, and people were cared for by staff who understood safeguarding procedures.

Improvements had been made and the previous recommendation and breaches had been met. Risks associated with people’s individual care and health needs were assessed and measures were in place to reduce the risk. Care plans had been reviewed, updated and personalised to reflect individual preferences, routines and wishes. Staff had detailed guidance of the action required to provide safe and effective care. People received their medicines in a safe way and in the way they preferred. There was improved guidance to enable staff to support people with their medicines.

People had enough to eat and drink and their dietary needs were met. People were supported to access health care services when required.

Staff had been safely recruited. There were enough staff working at the service to keep people safe. Staff were trained for their role. Staff felt supported by the registered manager and received feedback on their performance through supervisions.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Systems were in place to ensure the premises and equipment used in the delivery of care were serviced and maintained. People lived in a clean and hygienic environment. Improvements had been made to the recording of incidents and accidents. These were detailed and included any actions taken to reduce the risk of reoccurrence. Any learning was shared with staff.

The new registered manager had made significant improvements and understood their responsibilities. Staff and people had confidence in the registered manager. There were new and improved systems and processes were in place to monitor all aspects of the service provision and when shortfalls were found action was taken. People were involved in the review of their care and their equality and diversity needs were considered and respected. Feedback about the quality of service was sought from people, their relatives and staff and used to make improvements.

The service worked in partnership with other professionals and followed best practice guidance within the sector.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 18 May 2023) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service on 22 June 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve management of risks, medicines and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last inspection, by selecting the ‘all reports’ link for Margaret's Rest Home on our website at www.cqc.org.uk

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.