Care Home in Peterborough rated 'inadequate' and placed into 'special measures' to protect residents

The health watchdog has dropped the rating of St Margarets Care Home from ‘good’ to ‘inadequate’ and placed it into special measures to protect people, following an inspection in April.

The CQC says it inspected the home, in Aldermans Drive, because of safety concerns which had been raised.

In one instance, a CQC inspector said they had to “intervene” to prevent a resident from falling, when there “were no staff around” to help, adding that leaders had not ensured staffing levels were adequate.

The care home, run by Fins Care Limited, provides personal care for up to 16 older people.

At the time of this inspection,which took place across four unannounced visits in April, 15 people were living in the home, 11 of whom were living with dementia.

Despite people at the home and their representatives expressing satisfaction with their care and the service provided, the CQC says its assessment “found it did not meet the expected standards”.

It has now rated the home ‘inadequate’ for how safe, effective, caring, responsive, and well-led it is.

Being placed into special measures means it will be closely monitored to ensure people are kept safe while leaders make improvements. Special measures also provide a structured timeframe so services understand when they need to make improvements by, and what action CQC will take if this doesn’t happen. 

Stuart Dunn, CQC deputy director of operations in the East of England, said: “When we inspected St Margarets, we were deeply concerned to find people’s care wasn’t always safe, dignified, or centred on their needs. Our experience tells us that when a service isn’t well-led, it’s less likely they’re able to meet people’s needs in the other areas we inspect, which is what we found here.

“Leaders had tolerated worrying gaps in care planning, meaning staff lacked important information to keep people safe. For example, one person with epilepsy had no care plan or risk assessment, nor did people at risk of choking, putting them at a real risk of coming to harm.

“Leaders also hadn’t scheduled enough staff to meet people’s needs safely. People told us staff were slow to respond to call bells, and inspectors had to intervene to protect someone at risk of falling when there were no staff around.

“When leaders found concerns, such as unexplained bruising or falls, they’d failed to thoroughly investigate or report these to the local authority and CQC. This meant they missed opportunities to protect people from risk of abuse or neglect, or learn from incidents to prevent them from happening again.

“While we saw staff wanted to be kind, this was undercut by a culture of low expectations for people. Staff compared people to children when speaking with us, which wasn’t dignified, and didn’t always offer them choices about how or where they wanted to spend their time.

“Many people in the home were living with dementia or limited mental capacity, but leaders hadn’t always trained their staff well in how to meet their needs while respecting their rights.

“We’ve shared our concerns with the home’s management and told them exactly where improvements are needed. We’ll continue to monitor the service closely to ensure people receive safe care while this happens and won’t hesitate to take further action if it doesn’t.”

Councillor Shabina Qayyum, cabinet member for adults and health at Peterborough City Council, said: "We are dedicated to making sure all residents in our community get the best care possible. To support this, we regularly check on our care providers.

“During a visit earlier this year to St Margaret’s Home we found some areas related to processes in place and the layout of the building that needed improvement to ensure people living in the home are safe and their well-being is a priority. We flagged this to the provider, but unfortunately progress was not being undertaken at the rate we would have expected.

"Therefore we informed the Care Quality Commission who inspected St Margaret's Home in April and rated the home as inadequate with eight breaches of regulations identified. In addition, two enforcement notices of proposal were issued, which – if not remedied – could lead to the closure of the home.

“We have paused the placement of Local Authority residents to the home and have advised the provider not to take on additional residents.

“Residents and their families will have the opportunity to confirm whether they wish to stay at the home. If they do not wish to do so, we will support them in moving.

“We are working with the provider to fix the issues identified by the CQC. We are confident that the issues can be remedied within the allocated timeframe.

“We want to reassure those living in the home, their families and the public that we are committed to providing a safe and supportive environment for all people living in care homes in Peterborough.”

What the inspectors found

The following are findings from the CQC report, published on July 24.

• Leaders hadn’t maintained the home well or reduced environmental risks. The wood and paintwork were chipped. There was only one shower working, and two baths lacked working lifting equipment to help people get in.

• Staff didn’t always manage people’s medicines safely or administer them at the times they were prescribed for, which could impact their health.

• The home didn’t always provide meaningful or dementia-friendly activities. Some people said they felt isolated.

• The home didn’t always maintain people’s privacy. Staff shared monitoring photos of people’s skin conditions in a messaging service all staff could see.

• The home didn’t support people to make informed decisions about the end of their lives. Two people needed end-of-life care, but staff hadn’t recorded how they wished to be cared for.

• Leaders hadn’t always supported their staff with enough training, such as how to care for people with epilepsy, diabetes, or limited mental capacity.

• Leaders didn’t make it easy for people to share feedback or ideas, or raise complaints.

The local authority had previously raised similar concerns with the home’s management, but the CQC said “leaders hadn’t made timely improvements”.

The Peterborough Telegraph has attempted to contact Fins Care Limited, but had not received a response at the time of going to press.