CQC report explained · a residential care home
What the CQC found at Agape Annexe
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough trained staff, safe medicines administration, suitable infection control and systems for managing risks and safeguarding people. One person's smoking risk assessment needed more detail and the manager said it would be updated.
- Effective?
- Good
- People had detailed assessments and regular reviews. Staff had relevant training, supported people's health needs and followed the principles of the Mental Capacity Act.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff understood people's communication preferences, encouraged independence and involved people and relatives in care reviews.
- Responsive?
- Good
- Care was personalised and people were supported with activities, family relationships, communication and community access. Some care-plan wording was out of date and needed review.
- Well-led?
- Good
- Inspectors found positive leadership, regular checks, staff meetings and involvement of people in decisions. The rating improved from Requires Improvement at the previous inspection.
What inspectors found, March 2023
Agape Annexe rated Good; inspectors found kind, personalised care and safe staffing, with minor updates needed to risk records and care-plan wording.
This was an unannounced inspection on 7 March 2023. One inspector spoke with two people living at the home, one relative, one staff member and the registered manager. They also checked care plans, risk assessments, staff files and meeting records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found that people were treated with kindness and respect, supported to make choices, helped to access health care and encouraged to take part in activities and local life.
The inspection was partly prompted by concerns about staffing levels and also checked infection prevention and control. Inspectors found no evidence that people were harmed by the staffing concern. They found enough trained staff, safe medicines systems and suitable infection control arrangements.
Enough trained staff
Staffing numbers were consistent and inspectors found enough suitable trained staff to support people safely. The manager and provider also worked shifts and could cover absences promptly.
“There were enough suitable trained staff to support people safely.” from the report
Choice and independence
People were supported to make choices, follow their interests and use their local community. Staff used the least restrictive approach and encouraged independence.
“People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests” from the report
Kind and respectful care
Inspectors saw staff communicate patiently and in ways people preferred. People's privacy, dignity and human rights were promoted.
“People received care that was person-centred, and dignity, privacy and human rights were promoted.” from the report
Personalised care plans
Care plans recorded people's preferences, dislikes and goals. Staff understood how each person wanted to be supported.
“Care plans were person centred, and documented people's likes, dislikes, preferences and goals.” from the report
Smoking risk record needed more detail
needs fixingOne person's risk assessment about smoking did not contain enough detail. The registered manager said it would be updated immediately.
“some further detail was required to ensure that one person's risk around smoking was fully detailed.” from the report
Some care-plan wording was out of date
minorInspectors found minor examples of language in care plans that did not reflect current terminology or people's current needs. The manager said this would be changed immediately.
“There were some minor examples of language used within care planning which required review, as it was not always terminology which was up to date” from the report
Communal décor was tired
minorSome communal areas looked dated and tired, although people could personalise their own rooms and said they felt at home.
“whilst décor within some communal areas within the house was dated and tired, people were able to personalise their own rooms and felt at home.” from the report
- 01Has the smoking risk assessment been updated, and what exact risks and safety steps does it now record?
- 02Have all care plans been checked and updated where the wording did not reflect people's current needs?
- 03How do you maintain safe staffing levels when a member of staff is absent?
- 04How will you keep infection prevention and control arrangements effective during an outbreak?
This was an unannounced inspection that reviewed all five key questions, with particular attention to infection control and concerns about staffing levels; the previous overall rating was Good. This explanation was written from the published report of 15 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2018
Rated Good overall; inspectors found kind, safe care, but the home's leadership and quality checks required improvement.
Inspectors visited without notice on 25 April, 3 May and 8 May 2018. They spoke with all four people living in the home, a care worker and the provider. They also looked at care records, medicines, staff training, complaints and management records.
The home remained Good overall, as it was at the previous comprehensive inspection in March 2016. Safe, Effective, Caring and Responsive were all rated Good. People were supported by trained staff, received their medicines safely, had personalised care plans and were treated with kindness and respect.
Well-led was rated Requires Improvement. Inspectors found that some bedrooms and the main bathroom were not visibly clean, and some furniture needed replacing. These issues were addressed during the inspection, but the home's checks had not identified them early enough or regularly enough.
Kind relationships
People were treated with warmth, respect and compassion. Staff knew people well and involved them in conversations and decisions.
“People were treated with kindness, respect and compassion.” from the report
Personalised support
Care plans recorded people's histories, preferences, cultural and spiritual needs, and how they wanted to be supported.
“People had individualised care plans, which detailed the care and support people wanted and needed” from the report
Safe medicines
Staff were trained to manage medicines and their competence was checked regularly. Inspectors saw that medicines were given at the prescribed times.
“Medicines were safely managed. Staff had received training and their competencies were tested regularly.” from the report
Skilled staff
Staff received induction and ongoing training, with regular supervision to discuss their development and work.
“Staff received induction training based on current best practice and on-going training” from the report
Cleanliness and furniture
needs fixingSome bedrooms and the main bathroom were not visibly clean, and some furniture needed replacing. The provider addressed these issues during the inspection and new furniture had been ordered.
“Some people's personal rooms and the main bathroom was not visibly clean and some items of furniture required replacing.” from the report
Weak quality checks
needs fixingRegular audits did not properly check rooms where access was often declined. This meant the home had not identified the cleanliness and maintenance problems early enough.
“The audits in place to assess the quality and safety of the service required improving.” from the report
- 01How often are bedrooms, bathrooms and furniture now checked for cleanliness and repair?
- 02How do you carry out environmental checks when a person does not usually allow staff into their bedroom?
- 03What evidence can you show that the new cleaning arrangements and replacement furniture have been maintained?
- 04How do you check that staff have started each shift and that people are not left without the planned support?
- 05What changes have been made to improve the audits since the well-led rating became Requires Improvement?
This was an unannounced inspection over three visits that assessed all five areas and found the home Good overall, with Well-led rated Requires Improvement; the previous comprehensive inspection was in March 2016. This explanation was written from the published report of 18 July 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Agape Annexe
3 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 3 March 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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