St Margaret's Care Home Also known as Halle Healthcare Limited 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. We looked at 7 quality statements and found a breach of regulation concerning management oversight of this home. At this assessment, the rating has been assessed as inadequate. Leaders were not carrying out quality checks of the service, seeking feedback from people and staff, formal staff support was not recorded and support from partners had not led to improvements which were needed.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager told us about their plans for the future. However we found these were not being implemented safely. We found serious concerns about people's safety and the living environment. The registered manager and senior leaders showed a lack of understanding of how to safely care for people in a residential environment, as well as a lack of understanding of the relevant regulations.

The registered manager was not holding team meetings or resident and relatives meetings. Feedback from people, relatives and staff was not being sought to monitor and improve the service and to build a joint shared direction. This was a breach of regulation 17 (Good governance) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as there was a lack of accountability, knowledge and management oversight.

We received mixed feedback from staff in relation to how well supported they felt. The provider could not demonstrate that staff recruited from overseas had been recruited safely and in line with current guidelines and regulations. We shared our concerns with relevant partners.

The registered manager told us they supported staff. However, during this assessment we found staff were not given the training they required to do their jobs safely. Supervision and appraisals were not conducted and there was a lack of risk assessments and care plans to ensure staff had relevant information about how to care for people safety.

Staff told us they felt confident to speak up and bring up any issues to the management team; however, when some staff reported specific concerns which we reported to partners, these members staff did not feel confident raising this directly with the registered manager.

The registered manager told us they supported staff. However during our assessment, we found staff were not given the training they required to do their jobs safely, supervision and appraisals were not conducted, which could have given staff an opportunity to speak up about concerns.

Several months before our assessment, the registered provider had expressed a desire to make their workforce more diverse, but when we visited the premises, this had not happened.

Systems were not in place to make sure staff worked in an inclusive environment. Training, supervision and appraisals as well as team meetings were not taking place.

Although there was a management structure in place, there was a lack of leadership and accountability in the day to day running of the service. Leaders showed a lack of understanding of risks to people and were not taking responsibility for the oversight of these areas, as they did not understand what they needed to look for. This was a breach of regulation 17 (Good governance) of The Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as there was a lack of accountability, knowledge and management oversight.

There was a lack of quality assurance systems to ensure adequate oversight of the running of the home. Audits and other checks were either not taking place or showed significant gaps. The provider did not have systems of governance in place to ensure risks to people had been reduced.

People did not share feedback about how the provider worked with the wider community. However, during our assessment, we found the provider did not always work well with healthcare professionals to meet the needs of people, who were not involved; or did not always work well with partners by following best practice advice and support they offered.

The registered manager told us they worked with various professionals to meet the needs of people. However, during our assessment we found examples where this was not working in an effective way. For example, the service did not work well with the pharmacy to ensure one person who was nutritionally at risk had their supplement drinks at the service.

Following our assessment, a decision was made by partners to move people on from living at St Margaret’s, which was due to serious safety concerns. Despite consistently providing support and advice for several months, the lack of improvement in the quality of care resulted in this decision.

Systems and processes needed in order to make the necessary improvements were not in place.

The provider failed to take the necessary action to make immediate improvements needed. This demonstrated a lack of knowledge and insight.

Due to our serious concerns, we carried out a third site visit and continued to find people were at risk of harm. There had been limited action to address the issues we raised. Despite being aware of these concerns, the provider still failed to implement measures required to keep people. This placed people at an unacceptable risk of harm.