St Margaret's Care Home Also known as Halle Healthcare Limited 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 – We looked at 7 quality statements and found a breach of regulation concerning a lack of person-centred care. The provider did not actively seek out and listen to information about people who are most likely to experience inequality in experience or outcomes. Communication needs were not explored and end of life care needs had not been planned for.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they did not always feel they were at the centre of their care. Their feedback included, “There are no activities. I just watch the television.” Another person said they were unable to leave their bedroom as equipment they needed to do this had not been provided.

Leaders and staff demonstrated a lack of insight into how to provide person-centred care. They took choice away from people and did not empower them to make decisions as part of their daily routines.

We did not observe person-centred care being delivered. Interactions we saw showed staff were not giving people choices and respecting their individual rights.

People did not always feel well supported. One person told us they were not confident they would be allowed to leave the premises because they believed everything was “locked up”. They did not feel confident in asking staff to clarify their understanding.

Managers and staff were not delivering care in a way that met their needs or kept them safe.

Prior to our assessment, partners were supporting staff and leaders in the home to deliver person-centred care. However, they had continued concerns about the quality of care which had been the case for several months.

People's care was not delivered in a way that met their needs or kept them safe. We found a lack of care planning and risk assessment. Known risks to people's care, including diabetes, choking and weight loss, were not risk assessment or care planned. This placed people at risk of not receiving the care they required. During this assessment, we found examples of people not receiving the care they needed. For example, people being given a consistency of food which was not safe due to their risk of choking. This was a breach of regulation 9 (Person-centred care) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as essential information about people’s care was not documented.

The provider could not demonstrate that information was being provided to people in a way that was adapted to meet their needs. Some people living at the service lived with dementia, others did not speak English as their first language.

Staff and managers did not have a good understanding about adapting their communication to meet people's needs.

The provider did not have an equality, diversity and inclusion policy in place.

People told us they were not involved in care planning and information was not always tailored to their needs. People told us, “They (management) don't listen to us and they do not ask for our feedback” and “They are putting things in the wash, but they’re not dirty items. I ask them to not wash my clothes yet, but they take them. Nobody listens to me.”

Managers were able to explain the process they would follow to deal with complaints, meaning they knew how to respond according to their complaints policy. However, we found in practice this knowledge was not being applied in the way complaints were actually handled.

A copy of the complaints policy was provided. One complaint had been made. Although the registered manager told us they had completed an investigation and contacted the complainant, there was no evidence to show this had been done.

Staff failed to take action in response to a person having an emergency relating to their diabetic care. A visiting healthcare professional shared concerns with us about this service user’s diabetes care. Some people told us they accessed care, support and treatment they needed. One person told us, “The nurse comes for my catheter.”

Staff and leaders lacked knowledge around how they ensured people who held protected characteristics under the Equality Act received equity in their access to care.

Before and during our assessment, partners continued to have serious concerns about the safety of care provided. People were not sufficiently supported to access health and care services.

One person had been prescribed nutritional supplements, but these were not available on the first day of our assessment. We raised this with the registered manager. On our second visit, this person's nutritional supplements were still not available. Records of food intake for the same person showed several gaps in recording, which meant they were at increased risk of malnutrition.

Some people had different communication needs which needed to be supported. The provider had not explored this to ensure these needs were met.

Leaders and staff were not alert to discrimination and inequity, and did not take sufficient action to ensure people were protected from abuse. Care plans and risk assessments had not been created, which meant people did not receive equity in their outcomes.

The provider did not make adequate provision for people with protected characteristics to receive appropriate care for their needs.

People's end of life care or wishes were not recorded. We reviewed the care plans for people living at the home, including one person receiving end of life care. There were no care plans or risk assessments to show how this person should be cared for at this stage of their life.

After our on site visits, we were told by the provider that one person had been discharged from hospital requiring end of life care. We did not see any evidence of relevant care plans and risk assessments for this person.

Processes and oversight around the delivery of end of life care were absent. We were not assured the provider could deliver person-centred care for affected people.