CQC report explained · a residential care home
What the CQC found at Agnes House 81
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People received their medicines when needed, but records did not always show refusals or correct application times. Staff also had not recorded medicine stock accurately, and refresher medicine training was still awaited.
- Effective?
- Requires improvement
- Staff had the training needed for their roles but had not had refresher training for some time. Records about oral health lacked detail, and some repairs and renewal work had not been completed promptly.
- Caring?
- Good
- Staff treated people with respect, involved them in daily choices and supported their privacy, dignity and independence. Inspectors observed staff spending time with people and responding to their wishes.
- Responsive?
- Good
- People received personalised support and took part in activities they chose. Staff responded when a person became anxious, and people and relatives knew how to raise concerns.
- Well-led?
- Requires improvement
- Quality assurance systems did not reliably identify shortfalls or show that improvements were being made. The provider remained in breach of Regulation 17, although the manager was open to feedback and sent an action plan after the inspection.
What inspectors found, January 2020
Agnes House 81 was rated Requires Improvement; inspectors found kind, personalised care but weaknesses in medicines, records, repairs and management checks.
This was an unannounced planned inspection on 13 November 2019. One inspector spoke with the person living in the home, a relative, staff and the manager. They observed care and checked care records, medicine records, staff files, training records and quality checks.
The home was caring and responsive. Staff knew the person well, respected their choices, supported independence and helped them take part in activities and healthcare appointments. There were enough staff, and people said they felt safe.
However, medicine records and stock checks were not always reliable. Some repairs and renewal work had not been completed promptly. Care plans were not always updated when needs changed, and the home's checks did not reliably find or address problems. The home remained rated Requires Improvement, as it had been at the previous inspection.
Respect and choice
People were involved in decisions about their daily lives. Staff respected privacy, dignity and independence.
“We observed staff talking to one person about these choices and involving the person in all aspects of their care.” from the report
Staff knew people's needs
Staff understood the risks linked to supporting people and used agreed techniques when someone became distressed.
“Staff were knowledgeable about people's needs and were aware of any risks associated with supporting them and how to keep them safe and well.” from the report
Meaningful activities
People were supported to go out and take part in activities they chose, including shopping, church and coffee mornings.
“People were supported to engage in meaningful activities of their choice.” from the report
Healthcare support
People were supported to attend healthcare appointments, including appointments with dentists, opticians, psychologists and other professionals.
“Health action plans were in place which demonstrated people were supported to attend all required healthcare appointments” from the report
Medicine records and checks
seriousA cream was recorded as given after it had been refused, and records showed it was applied less often than prescribed. An old opening date was also recorded, and medicine stock did not always balance.
“The instructions on the prescribed cream stated it should be applied three times a day, but the medicine records showed this was only being applied twice a day.” from the report
Weak quality monitoring
seriousThe provider could not provide medicine audits or provider quality audits during or after the inspection. This meant inspectors could not confirm whether problems had been found and dealt with.
“This was a continued breach of regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Care plans not kept up to date
needs fixingA person's needs had deteriorated but their support plan had not been updated. The outcome of a deprivation of liberty assessment was also missing from the plan.
“People's records were not updated in response to changes.” from the report
Training refreshers overdue
needs fixingStaff said some refresher training, including safeguarding and first aid, had not been completed for a couple of years. Detailed oral health training was also lacking.
“I have completed all core training, but it has been a couple of years since I completed any refresher training in areas such as safeguarding, and first aid.” from the report
Repairs and cleaning
needs fixingSome repairs and renewal work had not been recorded or completed promptly. Cleaning schedules had gaps and some areas needed deep cleaning.
“We noted some areas in the home which required deep cleaning and this information was shared with the registered manager who told us action was being taken to address this.” from the report
- 01What changes have you made to record medicine refusals, application times, opening dates and stock balances?
- 02What medicine, training and quality audits are now completed, and how do you check that identified problems are fixed?
- 03When will all overdue refresher training, including safeguarding, first aid, medicines and oral health, be completed?
- 04How are repairs, renewal work and deep cleaning recorded, allocated and checked as complete?
- 05How quickly are support plans updated when a person's needs change, including decisions about future end-of-life wishes?
This was an unannounced planned inspection covering all five CQC questions, with observations, discussions and checks of care, medicine, staff and management records. This explanation was written from the published report of 10 January 2020 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, December 2018
Rated Requires Improvement; Agnes House 81 provided kind, safe and personalised care, but management systems were not reliable enough.
CQC carried out an unannounced comprehensive inspection on 22 October 2018. One person lived in the home, which can support up to two people. Inspectors observed care, spoke with the person, staff and a relative, and checked care, medicine, recruitment and management records.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found enough staff, safe medicine support, kind staff, consent-based care, support with health and nutrition, and activities based on the person's interests.
The Well-led rating was Requires Improvement. Quality checks had missed or failed to act promptly on problems, including outdated care records, cleaning and maintenance issues, insecure confidential information, an unrecorded complaint and gaps in staff supervision and meetings.
The overall rating changed from Good at the previous inspection to Requires Improvement. The Effective rating improved from Requires Improvement to Good, but the provider breached Regulation 17 on good governance.
Kind relationships
Staff understood the person's needs, personality and preferences. Inspectors saw a calm home with warm and caring interactions.
“We saw lots of chatting, laughing and warm, caring and kind interactions between the person and the staff supporting them.” from the report
Personalised activities
The person was supported to take part in activities that matched their interests, including shopping, colouring and sewing.
“We saw throughout our inspection that the person was supported to do the things that they wanted to do.” from the report
Consent and choice
Staff sought consent and involved the person in everyday decisions about activities, meals, clothing and how they spent their time.
“We saw during our inspection that staff made attempts to involve the person in day to day decisions, such as what they wanted to do and how they wanted to spend their time.” from the report
Weak quality checks
seriousThe provider's monitoring systems did not identify several problems or did not lead to prompt action. This was the reason for the Regulation 17 breach and the Requires Improvement well-led rating.
“The quality assurance systems were not effective and did not identify the shortfalls in the service.” from the report
Records not kept up to date
needs fixingSome care plans and risk assessments did not reflect changed needs. A record linked to a deprivation of liberty authorisation also had not been updated.
“For example, a person's mobility had deteriorated and their care plan and risk assessment had not been updated to reflect this.” from the report
Confidential information
needs fixingPersonal and confidential information was stored in an unsecured utility area. Inspectors also found information about someone from another service displayed in the home.
“We found that personal and confidential information was stored in an unsecured utility area used as a laundry and general storage room.” from the report
Maintenance and cleaning
needs fixingSome carpets were threadbare, redecoration was needed and areas required high-level cleaning. These issues had not been dealt with promptly or identified by recent checks.
“However, at the time of our inspection we saw areas in the home that required high level cleaning.” from the report
Limited staff feedback
minorStaff had infrequent supervision and there was limited evidence of staff meetings. The provider had started to address this.
“The assistant manager told us and records confirmed that staff supervision had been Infrequent.” from the report
- 01What action has been completed to make quality checks identify and fix problems promptly?
- 02Have all care plans and risk assessments been updated when people's mobility or other needs change?
- 03How are confidential records now stored securely, and has information from other services been removed?
- 04What repairs, carpet replacements and cleaning work have been completed since the inspection?
- 05How often do staff now receive supervision and attend staff meetings?
This was an unannounced comprehensive inspection covering all five key questions; one person lived at the home at the time and the home can support up to two people. This explanation was written from the published report of 5 December 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 Agnes House 81
3 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- January 2020Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- December 2013
Registered with the Care Quality Commission on 12 December 2013.
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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