# Lady Margaret Road

*Operated by Infinity Services (UK) Limited.*

Lady Margaret Road is a CQC-regulated home-care agency in Southall.

## CQC Ratings

| Key question | Rating |
| --- | --- |
| Overall | Good |
| Safe | Good |
| Effective | Good |
| Caring | Good |
| Responsive | Good |
| Well-led | Good |

Rating published: 01/05/2021

## Practical info

- Postcode: UB1 2PS
- Registered manager: Bhatt, Bhakta
- Local authority: Ealing
- Region: London
- City: Southall
- Last CQC check: 01/May/2021 - 00:00

## Inspection findings

### Other

- Finding
  - Evidence: Effective multi-agency working with local authority safeguarding team and healthcare professionals.
  - Published: 2021-10-30
- Finding
  - Evidence: Cultural and spiritual needs were respected, including food preferences, faith activities, and choice of staff gender.
  - Published: 2021-10-30
- Finding
  - Evidence: Quality assurance questionnaires were used regularly to gather feedback from people, relatives, and staff.
  - Published: 2021-10-30
- Finding
  - Evidence: Complaints were handled promptly and in line with procedure, with people feeling confident to raise concerns.
  - Published: 2021-10-30
- Finding
  - Evidence: People were supported to maintain independence, engage in meaningful activities, employment, and community participation.
  - Published: 2021-10-30
- Finding
  - Evidence: Proactive and experienced registered manager with strong governance, regular audits, and an open and transparent culture.
  - Published: 2021-10-30
- Finding
  - Evidence: Care plans were detailed, person-centred, and signed by people using the service, reflecting individual needs, preferences, and diversity.
  - Published: 2021-10-30
- Finding
  - Evidence: Staff received comprehensive induction, mandatory and specialist training, regular supervision, and annual appraisals.
  - Published: 2021-10-30
- Finding
  - Evidence: Robust medicines management with completed MAR charts, secure storage, PRN protocols, and medication information sheets for all prescribed medicines.
  - Published: 2021-10-30
- Finding
  - Evidence: People consistently reported feeling safe, with strong trust in staff and management across both Scott's Road and Shrubbery Road locations.
  - Published: 2021-10-30
- Finding
  - Evidence: Leadership was described as supportive, approachable and hands-on by people, relatives and staff.
  - Published: 2021-10-30
- Finding
  - Evidence: People were supported to develop independence skills, with some successfully moving on to independent living.
  - Published: 2021-10-30
- Finding
  - Evidence: MCA principles were applied correctly; nobody was deprived of their liberty unlawfully at time of inspection.
  - Published: 2021-10-30
- Finding
  - Evidence: Complaints processes were accessible including easy-read formats; complaints addressed appropriately and in a timely manner.
  - Published: 2021-10-30
- Finding
  - Evidence: Incidents and accidents were recorded, analysed for trends, discussed with staff, and used to update support plans.
  - Published: 2021-10-30
- Finding
  - Evidence: Care plans were clear, comprehensive and person-centred, covering all aspects of people's lives and regularly reviewed.
  - Published: 2021-10-30
- Finding
  - Evidence: People felt safe and were treated with dignity, compassion and respect; staff supported independence and cultural/religious needs.
  - Published: 2021-10-30
- Finding
  - Evidence: Risk assessments were detailed, regularly reviewed monthly, and person-centred including environmental and personal risks.
  - Published: 2021-10-30
- Finding
  - Evidence: Staff were well-trained, supervised and appraised, with up-to-date mandatory and specialist training confirmed by training matrix.
  - Published: 2021-10-30
- Finding
  - Evidence: Medicines management was safe; MAR charts signed correctly with no errors, regular thorough medicines audits in place.
  - Published: 2021-10-30
- **other** _(critical)_
  - Evidence: there were two large wooden drawers discarded on the grass which contained pieces of sharp wood with nails sticking out...a pile of loose bricks which could have fallen and caused harm.
  - Published: 2021-10-30
- **governance** _(critical)_
  - Evidence: The provider's audits of the supported living schemes had identified infection control risks but no action had been taken to mitigate these.
  - Published: 2021-10-30
- **infection_control** _(critical)_
  - Evidence: there were cobwebs on ceilings and thick dust on skirting boards and other surfaces. There were dried up food splashes above the cooker and tiles were not clean.
  - Published: 2021-10-30

### responsive

- Finding
  - End of life care and support
  - Published: 2021-10-30

### well_led

- Finding
  - Working in partnership with others
  - Published: 2021-10-30
- Finding
  - Continuous learning and improving care
  - Published: 2021-10-30
- Finding
  - Engaging and involving people using the service, the public and staff
  - Published: 2021-10-30
- Finding
  - How the provider understands and acts on the duty of candour
  - Published: 2021-10-30
- Finding
  - Promoting a positive culture that is person-centred, open, inclusive and empowering
  - Published: 2021-10-30
- Finding
  - Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirements
  - Published: 2021-10-30

## Source

Data published by the [Care Quality Commission](https://www.cqc.org.uk/) under the Open Government Licence v3.0. Canonical page: https://homecarecompass.co.uk/agency/1-2145877356

HomeCare Compass is an independent guide and is not affiliated with the CQC.