CQC report explained · a residential care home
What the CQC found at Agnes House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, August 2019
Rated Requires Improvement; inspectors found safe, kind and responsive care, but weaknesses in training, the building and management.
This was a planned inspection on 25 June 2019. The inspector reviewed care and medicines records, staff recruitment and supervision files, training information, policies and quality checks. They spoke with staff, a relative and a visiting professional. They could not speak directly with the people living in the home because of their needs.
The home was rated Good for Safe, Caring and Responsive. Inspectors found people were protected from abuse, received medicines safely, were treated with dignity, and received personalised support. People were also supported to eat and drink enough and to access the community.
The home was rated Requires Improvement for Effective and Well-led. Inspectors found a bedroom ceiling needed repair, the garden was overgrown, some staff training had expired, mental capacity decisions were not properly recorded, and management checks did not always identify or fix problems promptly.
The overall rating fell from Good at the previous inspection, published in December 2016. The Effective rating remained Requires Improvement, while Well-led fell from Good to Requires Improvement. CQC said it would continue monitoring the home and could inspect sooner if it received concerning information.
Safe medicines support
Medicines were stored securely and records were completed. Stock levels and guidance for medicated creams were also checked.
“Medicines were kept securely, and medication administration records had been completed.” from the report
Staff knew people well
Inspectors found that staff understood people's communication needs, preferences and routines. People appeared comfortable approaching staff.
“From our observations, staff knew people well and people felt comfortable approaching staff.” from the report
Personalised care
Care plans included people's likes, dislikes and routines. Staff offered choices in ways suited to each person.
“People received personalised care that was responsive to their needs.” from the report
Community access
People regularly accessed the community, took part in activities and visited family members.
“People were supported to access the community on a regular basis and engage in activities.” from the report
Maintenance problems
needs fixingA hole in a bedroom ceiling needed repair. The garden was overgrown and staff and a relative were concerned about the risk this posed.
“The building required maintenance to meet people's needs effectively.” from the report
Out-of-date training
needs fixingSeveral staff training records had expired, including safeguarding, Mental Capacity Act and behaviour management training. This meant staff skills were not always refreshed promptly.
“We viewed the providers training record which showed several gaps for staff where their training had expired.” from the report
Mental capacity records
needs fixingCare plans referred to best-interest decisions, but records did not show how those decisions had been reached. This also affected applications for safeguards when people were deprived of their liberty.
“People's care plans referred to people lacking capacity and decisions were made in their best interests, however there was no documentation in place to evidence how this decision had been reached.” from the report
Limited family involvement
needs fixingRecords did not always show people's involvement in care planning. A relative said key worker meetings had not happened for a long time, and relatives reported difficulty contacting the manager.
“It was not always evident how people were involved in making decisions about their care.” from the report
- 01What repairs have been completed to the bedroom ceiling, and how is the garden now being kept safe?
- 02How do you ensure all staff have current safeguarding, Mental Capacity Act and behaviour management training?
- 03How are mental capacity assessments and best-interest decisions recorded now?
- 04How do your audits identify problems, and how do you check that repairs and other actions are completed promptly?
- 05How will relatives be involved in care planning and contact the registered manager?
This was a planned inspection covering all five CQC questions, but inspectors could not speak directly with the people living in the home. This explanation was written from the published report of 7 August 2019 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 2016
Rated Good overall; inspectors found safe, kind and responsive care, but staff training had expired and effective care was rated Requires Improvement.
The unannounced inspection took place on 7 November 2016. The inspector spoke with people, a relative, staff, the manager and a healthcare professional. They also observed care and checked care records, medicines, recruitment, training, complaints and quality checks.
The home was rated Good overall, and was rated Good for Safe, Caring, Responsive and Well-led. People appeared safe, comfortable and treated with kindness. Staff understood people's needs, supported activities and maintained links with families.
The Effective rating was Requires Improvement. Several staff had overdue refresher training, including behaviour management training. There were also gaps in medicine records and staff were not sure about conditions attached to some liberty safeguards. The report says improvements were already being made.
Kind and respectful care
Inspectors saw staff being kind and compassionate. People were supported to make choices, maintain privacy and do things for themselves.
“People were treated with kindness and respect by staff who knew them well.” from the report
Individual support
Care plans gave staff detailed guidance about people's complex needs. Activities were based on each person's interests and preferences.
“Support plans were in place which were detailed and tailored to the support needs of the person.” from the report
Safe staffing and risk support
Inspectors found enough staff to meet people's needs. Risks linked to health, behaviour and the environment had been identified and managed.
“Potential risks to people's well-being were well managed.” from the report
Open management
Staff said they were supported by the management team and could raise suggestions or concerns. Feedback and quality monitoring systems were in place.
“Systems were in place to monitor the quality of the service provided.” from the report
Overdue refresher training
needs fixingSeveral staff had training that had expired under the provider's renewal timescales. This included behaviour management training, so staff's skills and knowledge had not always been updated promptly.
“Staff training had expired which meant staff did not have refresher training in a timely manner to ensure their skills and knowledge were updated.” from the report
Medicine records
needs fixingVariable doses were not always recorded, tablet stock counts were not completed and body maps were not in place for prescribed creams. The manager said action would be taken.
“We found that variable doses had not always been recorded, and a stock count of tablets contained in bottles was not completed.” from the report
Liberty safeguard information
needs fixingStaff knew which people had authorisations restricting their liberty, but were unsure about conditions attached to them. This could affect how staff supported people in the least restrictive way.
“However staff were unsure if there were any conditions on a person's authorisation.” from the report
Annual appraisals
minorThe manager said staff annual appraisals were behind schedule. A plan was in place to start providing them.
“The registered manager advised that they were behind in providing staff with their annual appraisals.” from the report
- 01Have all staff now completed the overdue refresher training, especially behaviour management training?
- 02How are variable medicine doses, tablet stock counts and prescribed creams recorded now?
- 03How are staff told about conditions attached to authorisations restricting a person's liberty?
- 04Have all staff annual appraisals been completed, and how are they being kept up to date?
- 05What action was taken after the inspection to make provider monthly quality audits regular?
This was an unannounced inspection of the overall quality of the home and all five CQC questions, using observations, discussions and records. This explanation was written from the published report of 24 December 2016 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
3 rated inspections over 4 years: the service has held its Requires improvement rating throughout.
- August 2019Requires improvementcurrent ratingdown from GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016Goodup from Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- November 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- April 2012
Registered with the Care Quality Commission on 19 April 2012.
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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