Agnes Court - Care Home with Nursing Physical Disabilities

We found 4 breaches of regulation in relation to safeguarding, consent, person-centred care and good governance.

People and relatives described concerns regarding delays in receiving support and reduced opportunities to access community activities, hobbies and therapeutic services. Some people told us they wanted greater independence and choice in their daily lives. However, people also told us they felt safe and enjoyed activities, relationships with staff and opportunities to socialise. Staff worked effectively with healthcare professionals to support people's physical health needs. The home was clean, infection prevention and control arrangements were effective, and medicines were stored securely.

Risks to people's safety were not always effectively identified, assessed or managed. Leaders had failed to recognise and investigate some safeguarding concerns, incidents were not always recorded, and risk assessments did not consistently provide staff with clear guidance about supporting people safely whilst promoting independence. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. Records relating to mental capacity assessments and best interest decisions did not consistently demonstrate compliance with the Mental Capacity Act 2005, meaning the provider could not always evidence that restrictions or decisions made on people's behalf were lawful and proportionate.

Governance systems were not consistently effective. Although audits, quality assurance processes and service improvement plans were in place, these had failed to identify a number of concerns found during the assessment, including shortfalls in care planning, risk management, medicines oversight, safeguarding processes and Mental Capacity Act compliance. People, relatives and staff spoke positively about the registered manager and described them as visible, approachable and supportive.

We have asked the provider for an action plan in response to the concerns found at this assessment. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.