CQC report explained · a residential care home
What the CQC found at St Agnes Retirement Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors looked at infection prevention and control but did not review the whole Safe key question. They were assured that the home used protective equipment safely, supported visiting and had arrangements to prevent and manage infections.
- Effective?
- Good
- People were supported with food, drinks, healthcare and choices about their care. Improvements had been made to the environment and to applications for legal safeguards, although some records about people's ability to make decisions were not clear.
- Caring?
- Good
- This key question was not reported as inspected in this report. The report did say that people were listened to and respected, and that staff had positive relationships with them.
- Responsive?
- Good
- The home provided more meaningful activities, helped people access the community and supported relationships with family and friends. Care plans included people's routines, interests and preferences, but end of life plans still needed to be more personal.
- Well-led?
- Requires improvement
- The home had improved its audits and had an improvement plan, but checks had not identified some problems found by inspectors. Care plans, supervision records, feedback surveys and some signage needed further work.
What inspectors found, July 2022
St Agnes Retirement Home is rated Good overall; inspectors found kind, effective care and better activities, but management systems still needed improvement.
This was an unannounced follow-up inspection on 7 June 2022. Inspectors spoke with eight people living at the home, four relatives and seven staff. They reviewed six care records and records about how the home was managed.
People were treated with respect and staff knew them well. The home was clean, people enjoyed their rooms and garden, and staff supported nutrition, healthcare, activities and family relationships. Improvements had been made to activities, mental capacity checks and end of life planning.
The main weakness was how the home checked and recorded the quality of care. Some care plans were not accurate or personal enough, some staff supervision records were incomplete, and feedback surveys were not easy for people to use. The overall rating improved from Requires Improvement to Good, but the well-led rating stayed Requires Improvement.
Meaningful activities
Activities had improved since the previous inspection. People could take part in group activities, receive one-to-one support and go out into the community.
“The service had made improvements to ensure people had meaningful activities to engage in.” from the report
Food and healthcare
People were offered choices about meals and drinks and received support with their nutrition and hydration. Staff helped people access doctors and other healthcare appointments.
“People were supported well with their nutrition, hydration and healthcare needs.” from the report
Clean environment
Inspectors found the home clean and tidy. People were happy with their rooms and had access to outdoor space.
“The home was clean and tidy. People enjoyed their individual rooms and the outdoor space at the home.” from the report
Care records and quality checks
needs fixingSome care plans were not accurate or personal enough, including records about end of life care and decision-making. The home's checks had not found all the issues identified by inspectors.
“We recommend the provider takes action to ensure governance systems are fully effective.” from the report
Staff supervision
needs fixingThree staff members had not received supervision in the previous 12 months. Some records did not clearly show what had been discussed.
“However, we did find three staff members who had not received a supervision in the last 12 months.” from the report
Feedback surveys
minorSome surveys were too long or difficult for people to complete independently. This limited how useful the feedback was for improving the home.
“The surveys were not always easily accessible for people to complete independently due to the length, style and format.” from the report
End of life plans
needs fixingEnd of life plans were now in place, but the home accepted that they were not always personal and individual enough.
“The provider acknowledged that further development was needed to ensure these plans were person-centred and individualised.” from the report
- 01How have you improved the accuracy and personal detail in people's care plans?
- 02How do you make sure staff receive regular supervision and that each session is recorded fully?
- 03How are you making end of life care plans personal to each resident?
- 04How can residents who cannot complete long surveys independently give feedback?
- 05What changes have been made to the signage to help people find their way around the home?
This was a follow-up inspection of actions from previous inspections, including Effective, Responsive and Well-led, and infection prevention under Safe; Safe was not fully rated and the report does not give a current Caring rating. This explanation was written from the published report of 1 July 2022 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 2021
Rated Requires Improvement; the home was safer and no longer in special measures, but its quality checks still needed strengthening.
This was an unannounced focused inspection on 12 January 2021. Inspectors checked Safe and Well-led, including infection control, records, medicines, recruitment and management systems. They spoke with people, relatives and staff and reviewed care, medicine, recruitment and audit records.
The home was rated Good for Safe. Inspectors found improvements to hot water, radiators, fire safety, safeguarding, medicines and infection control. Staffing levels were considered safe, although one recruitment file did not contain a reference from the person's previous health and social care employer. Written instructions for giving medicines did not always match the practice described.
The home was rated Requires Improvement for Well-led. Management had improved and was no longer in breach of the regulations checked, but audits did not always give enough detail and there was no further development plan. The overall rating improved from Inadequate to Requires Improvement, and the home was no longer in special measures.
Safer environment
Risks from hot surfaces and water had been addressed. Fire safety actions had also been completed, with regular testing and personal evacuation plans.
“All radiators at the service were now covered to ensure the risk to people from hot surfaces was reduced.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection, including PPE, testing, visiting and cleaning.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Positive atmosphere
People and relatives described the home as welcoming and happy. Staff were described as valued and working well together.
“There was a positive and welcoming atmosphere. One person said, "All the staff are lovely.” from the report
Communication
Relatives said they received updates and that the home responded to emails and concerns.
“We get communication by phone if there is a problem, we get newsletters, that works well.” from the report
Medicine instructions
needs fixingSome medicine profiles said medicines were left with people, but the provider said this did not happen. The written instructions needed to reflect the actual safe practice.
“We recommend the service considers current guidance in the administration of medicines and ensures written instructions reflect this.” from the report
Audits lacked detail
needs fixingQuality audits were in place, but they did not always show which records had been checked or clearly identify improvements needed.
“We highlighted to the provider where further details were needed to evidence their findings and drive improvements.” from the report
No further development plan
needs fixingThe previous inspection action plan had been completed, but the home did not yet have a further plan for ongoing improvements and refurbishment needs.
“However, there was no further development plan.” from the report
Recruitment record
minorOne staff file did not contain a reference from the person's previous employer in health and social care.
“However, we did find one staff member whose reference from their last employer in health and social care had not been received.” from the report
- 01How have you changed the written medicine instructions so they match what staff do in practice?
- 02How will your audits show which care plans and medicine records have been checked?
- 03What is your current plan for refurbishment and other ongoing improvements?
- 04How do you check that every recruitment file contains the required employment references?
- 05What were the previous ratings for Caring, Effective and Responsive, which were not reviewed during this inspection?
This was a focused inspection of Safe and Well-led only; the ratings for Caring, Effective and Responsive were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 12 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.
Every inspection of St Agnes Retirement Home
5 rated inspections over 6 years: the service has held its Good rating throughout.
- July 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2021Requires improvementWell-led: Requires improvement
- February 2020Inspected but not ratedSafe: Inspected but not rated
- November 2019Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- October 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 10 November 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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23 live-in carers within about an hour of North Somerset
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Most charge £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
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