St Margaret's Care Home Also known as Halle Healthcare Limited 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. Following this assessment, we have rated safe as inadequate. We reviewed 8 quality statements. Medicines were not safely managed. Not all staff received training to enable them to keep people safe. The provider did not have an effective safeguarding process in place. Risks to people had not been adequately assessed, monitored and reviewed. We identified 5 breaches of regulation in relation to safe care and treatment, safeguarding people from abuse, premises and equipment, as well as recruitment practice.

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 were not always able to speak to staff or management with concerns around safety. Some comments included, “They (management) hate me here now (since reporting a safeguarding incident). They call me a liar too” and “I don’t trust them to look into it (safeguarding incident), they won't bother.”

The registered manager did not know where they could access accident and incident records. They did not show an understanding of the importance of analysing these events to help reduce the risk of them happening again.

We found a lack of evidence that accidents and incidents were being recorded. Accidents and incidents that occurred several months before our assessment were being recorded on the days of our assessment visits. Trends and patterns were not analysed to reduce the risk of these events happening again.

People told us they did not always feel safe with systems and transitions. One person told us the provider had not arranged equipment they needed, which meant they were unable to leave their bedroom.

The registered manager and senior staff members were not clear about safe systems needed to admit new people to the home. The registered manager did not carry out their own pre-assessment and relied on information provided by other professionals. Following our visit, the provider developed a pre-admission assessment tool.

Partners had been providing resources and support for the provider in the months leading to our assessment. However, they expressed ongoing concerns about the provider’s ability to meet people’s needs through safe systems, pathways and transitions.

People were not supported to move safely between different services. Effective assessment and discharge arrangements were not in place. People’s care plans did not contain important information.

People gave mixed feedback about how safe they felt at this home. One person told us, “No (I don’t feel safe), my things get stolen.” Another person reported money going missing from their bedroom. A further person said, “Yes, I feel safe here.”

Staff showed a lack of understanding around signs of abuse, although they told us they would escalate any concerns to managers. However, during this assessment, we were not assured staff training had been effective, because we identified several safeguarding concerns that had not previously been identified or acted upon by managers and staff. The registered manager was not clear on their responsibilities around identifying and reporting safeguarding concerns. We followed up on these concerns with the registered manager and the local authority safeguarding team.

Due to the seriousness and widespread concerns found during our site visits, we shared safeguarding concerns relating to 5 incidents with the local authority about organisational abuse and neglect.

There were inadequate systems to protect people from the risk of abuse. We asked to see evidence of safeguarding and whistle blowing policies and procedures, but these were not provided. In our review of staff files, we found some staff had not received training in safeguarding people from abuse and neglect. This was a breach of regulation 13 (Safeguarding people from abuse) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as people were not adequately protected from the risk of abuse.

People did not always feel involved or supported in managing risks to them. One person told us, “They (staff) never let me out, even though I just want to go out for a walk or anything. Not even in the garden.” We explored concerns about restrictions placed on people as part of their care arrangements and where appropriate, we shared our concerns with the local authority safeguarding team.

We were not assured leaders and staff always knew how to safely manage risks to people. The registered manager did not have oversight of the risks linked to people's care. During this assessment, we found serious concerns about people not being safe and not receiving the care they required. We found concerns with staff understanding of fire safety procedures, nutrition and safeguarding.

We identified some service users’ needs were not met in respect of management of their diabetes, falls, skin integrity, weight loss and swallowing difficulties. This meant people were placed at significant risk of being harmed and their health and wellbeing deteriorating.

We found a lack of detailed risk assessments and care plans. Concerns were identified around the safety of the premises and the fire safety equipment. Some people did not have a personal emergency evacuation plan in place. Processes needed to safely manage and meet these care needs were not in place. This was a breach of regulation 12 (Safe care and treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as steps had not been taken to adequately reduce the risk of harm to people.

People told us they had access to their call bells. Whilst there were no comments from people regarding their living environment, we saw this was not safe.

The registered manager did not have oversight of the risks linked to the living environment and works being undertaken.

We found several examples of people having access to areas that were hazardous, because of tools and other building equipment being accessible. We asked the registered manager to take immediate action to ensure people did not have access to a bathroom that was undergoing renovation, as well as lift that gave access to 2 other floors that were also under renovation. We found fire evacuation routes obstructed and extinguishers were not in date or accessible.

We found the environment was not safe for people. The home was under renovation, but there were no renovation plans or risk assessments in place for this. We found a fire door that was bolted, which had been identified in a health and safety audit dated March 2024. However, no action to resolve this had been taken. We asked the registered manager to take immediate action. This was a breach of regulation 15 (Premises and equipment) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as risks to people in the living environment were not adequately managed.

People did not always feel staff had effective training to support people. People also told us staff were rushed and staffing was not always consistent. Comments included, “I do see a lot of different staff, different faces regularly” and “I don’t think the staff have enough training to look after people.”

The provider was unable to demonstrate staff had received the necessary training and support to understand their roles and ensure people were kept safe. A staff member told us they would turn off the fire alarm if it rang, without checking if there was a fire in the building or following any fire safety procedures. We found concerns with staff knowledge around people's medication. This was a breach of regulation 18 (Staffing) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as staff had not been consistently provided with relevant training needed for their role. Staff were not safely recruited. None of the staff files we looked at contained an application form, professional references, interview notes as well as DBS checks. This was a breach of regulation 19 (Safeguarding people from abuse) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as people were not adequately protected from the risk of abuse.

The provider did not have a training and supervision matrix to ensure appropriate oversight of this area. The document provided was blank. Staff lacked knowledge in key aspects related to meeting people’s care needs.

There was a recruitment policy in place, but we found this was not always being followed. The provider was not using a dependency tool to assess the required numbers of staff on shift to ensure people's needs were met. We found the rota in place was not always followed and were not assured there was appropriate oversight of the rota.

People did not raise concerns regarding cleanliness in the home.

Not all staff received training in infection and prevention control. The registered manager did not have good oversight of infection control risks. Infection prevention and control audits were not being carried out.

The environment was not clean. Several bedrooms and communal toilets had very strong malodours. This put service users at risk of illness from the spread of infection.

There were policies and procedures in place covering infection prevention and control, but these were not being followed.

We found examples of people having run out of supplies of their medicines, but a lack of effective processes meant action had not been taken. This was a breach of regulation 12 (Safe care and treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as systems were not in place to ensure people received their medicines as prescribed.

Medicines were not safely managed. Staff knowledge about medicines administration was not robust and managers did not have sufficient oversight of this area.

Systems were not in place to demonstrate oversight of the safe management of medicines. Essential information was not listed on medication administration records. The electronic system in place to record people’s medicines was unsafe. After our visit, a paper record was put in place but this still had essential information about people’s medicines missing. Self-medication was not safely managed, and the policy was not followed. Protocols for ‘as and when’ required medicines were not always person centred and did not give enough information for the medicines to be administered safely. Some medicines that should be given before food had not been identified and were not given safely. Covert medicines were not managed safely, The registered manager was not completing medication audits.