Working at St Margarets Nursing Home

Risks to residents like choking incidents and wrong mattress settings aren't managed, and medication records have gaps with no error reporting system.

one person had experienced 3 choking events in a year. Their care plan had not been reviewed... 4 people were sleeping on air mattresses that were incorrectly set... records for application of creams... not always recorded... no system for reporting any medicines errors

Enough staff on shift but poor deployment means long waits for call bells, and hiring misses full job history checks and references.

staff were not always deployed effectively to enable prompt responses to people’s requests for support... records showed employment histories had not been fully explored via application forms or interviews and references had not been consistently sought

Weak oversight fails to spot and fix care plans, risks, and record problems before they get serious.

Governance systems had failed to identify and rectify the significant concerns found at this assessment. People were not receiving person-centred care, significant risks... had not been identified and mitigated. Medications were not managed safely, and people’s care plans were inaccurate.