CQC report explained · a residential care home
What the CQC found at St Agnells House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured that the home was managing visitors, social distancing, admissions, personal protective equipment, testing and its infection control policy safely. They recommended improvements to cleaning during an outbreak and to allocating staff to specific cleaning tasks.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, February 2021
Inspected but not rated; inspectors found good infection control arrangements, but asked for improvements to cleaning during an outbreak.
This was an unannounced, targeted inspection on 4 February 2021. It focused on infection prevention and control because of coronavirus outbreaks in care homes.
Inspectors were assured that the home used personal protective equipment safely, followed social distancing and shielding rules, arranged testing, and had an up-to-date infection control policy. Visitors were not allowed, but people were supported to keep in touch with family by video calls.
The home had care plans, risk assessments, permanent staff and plans to cover shifts if staff had to self-isolate. Inspectors recommended checking current best-practice guidance for cleaning during an outbreak and allocating staff to specific cleaning tasks. The service was inspected but not rated.
Personal protective equipment
Staff were using personal protective equipment in line with national guidance and had infection prevention and control training.
“Staff followed national guidance in wearing their Personal Protective Equipment (PPE) and had training in infection prevention and control(IPC).” from the report
Keeping families in touch
Although visitors were not allowed at the time, people were supported to contact their families by video call.
“Visitors were not allowed in the home but people were supported to stay in touch with their family through video calls.” from the report
Planning for an outbreak
People had care plans and risk assessments, and the home had permanent staff and plans to cover shifts if staff needed to self-isolate.
“There were permanent staff working at the service and contingency planning was in place to ensure shifts could be covered in case staff had to be self-isolating.” from the report
Cleaning during an outbreak
needs fixingInspectors recommended that the home use current best-practice guidance for cleaning and infection control during an outbreak. They also asked for staff to be allocated to specific tasks so cleanliness could be maintained.
“We recommended that the provider consults current best practice guidance for effective cleaning and infection control in an outbreak and ensures that staff are allocated to specific tasks so that a high standard of cleanliness can be achieved in the service.” from the report
- 01What current best-practice guidance do you now use for cleaning and infection control during an outbreak?
- 02How are staff allocated to specific cleaning tasks, and how do you check that a high standard of cleanliness is achieved?
- 03How do you arrange testing for people living here and staff?
- 04What contingency arrangements are in place if staff need to self-isolate?
- 05How will people keep in touch with their families if visiting restrictions remain in place?
This was a targeted, unannounced inspection of infection prevention and control only; the service was inspected but not rated. This explanation was written from the published report of 23 February 2021 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, February 2018
Rated Good; inspectors found kind, safe and personalised care, with some improvements needed in staff training, capacity assessments and the environment.
This was an unannounced inspection on 23 January 2018. The inspector spoke with people living in the home, relatives, staff and the registered manager. Records, medicines, training and quality checks were also reviewed.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People and relatives said they felt safe and were happy with the care. Inspectors saw staff supporting people patiently, respectfully and without rushing.
People were supported with healthcare, food, activities, hobbies and holidays. Staff understood people's preferences and communication. However, some staff needed more training about mental capacity and restrictions on liberty. Some capacity assessments were not fully recorded, and parts of the building needed cleaning and redecoration.
Safe support
People and relatives said they felt safe. Staff responded promptly and risk assessments were updated when people's needs changed.
“People told us they felt safe at the home and they liked the way staff supported them to live the life they wanted.” from the report
Patient staff
Inspectors saw that staff gave people enough time and responded when they asked for help.
“Throughout the inspection, we saw that staff were unhurried and took the necessary amount of time needed to support each person.” from the report
Personalised activities
People were supported to follow their interests, take part in activities and go into the community. Trips and holidays were also available.
“Opportunities were provided for people to take part in meaningful activities and social interests relevant to their individual needs and requirements, both at the home and in the community.” from the report
Kind and respectful care
Staff knew people well and supported their dignity, privacy, choices and relationships.
“We saw staff interacted and responded to people in a positive manner and spent time with them.” from the report
Quality monitoring
The manager used audits and action plans to identify and make improvements. Staff also reported better teamwork and morale.
“The registered manager carried out regular audits and any actions needed to improve the service were promptly identified and actioned.” from the report
Mental capacity training
needs fixingSome staff needed more training to fully understand the rules about making decisions for people who may lack capacity and about restrictions on liberty.
“However some more training was needed for staff to understand fully the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).” from the report
Incomplete capacity records
needs fixingSome mental capacity assessments did not clearly show how decisions about people's capacity had been reached. The manager said these were being reassessed and recorded.
“However for some people mental capacity assessments had not been completed thoroughly for the reader to understand how they had assessed and established if people lacked capacity to take certain decisions or not.” from the report
Cleaning and repairs
needs fixingInspectors found cobwebs on high ceiling beams, dirty windows and chipped window frames. Further work was also needed to refresh the environment.
“However we saw that the high ceiling beams had cobwebs, some windows needed to be cleaned and some window frames were chipped which could potentially present as an infection control risk.” from the report
- 01What further training have staff completed on the Mental Capacity Act and Deprivation of Liberty Safeguards?
- 02Have all mental capacity assessments been reviewed and rewritten so the decision-making process is clear?
- 03Have the high ceiling beams and windows been cleaned, and have the chipped window frames been repaired?
- 04Has the planned redecoration and other work to refresh the environment been completed?
- 05How are people's activities, community trips and holidays matched to their individual interests and needs?
This was an unannounced inspection covering all five CQC areas, with the overall rating and each individual rating assessed as Good. This explanation was written from the published report of 14 February 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 St Agnells House
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- February 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- February 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 25 November 2010.
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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