We carried out a review of the data available to us about Agape Annexe on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Agape Annexe, you can give feedback on this service.
Agape Annexe is a residential care home providing personal care to up to 4 people. The service provides support to people with learning disabilities and autism. At the time of our inspection there were 3 people using the service.
We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.
People’s experience of using this service and what we found
Right Support:
People received care and support to maintain an environment that suited their needs and preferences.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Staff supported people to access health and social care services. Staff supported people with their
medicines safely and in their preferred way.
Staff supported people to make decisions following best practice in decision-making. People were
supported to carry out their daily living activities and pursue their hobbies and interests.
Right Care:
Staff communicated with people in ways that met their individual needs.
People received care that was person-centred, and dignity, privacy and human rights were promoted.
People received kind and compassionate care. Staff understood and responded to people's individual needs. They protected and respected people's privacy and dignity.
People's care plans reflected their needs and wishes and promoted their wellbeing. Risks that people may face were appropriately managed.
Staff understood how to protect people from poor care and abuse. Staff had training on how to recognise and report abuse and they knew how to apply it. The service employed skilled staff to meet people's needs and keep them safe.
Right Culture: The ethos, values, attitudes and behaviours of the registered manager and staff team ensured people lead confident, inclusive and empowered lives.
People received good quality care and support because trained staff and specialists could meet their needs and wishes.
People and those important to them, including social care professionals, were involved in planning their care. The registered manager and the staff team ensured people received support based on best practice, respect and inclusivity.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good, published 18 July 2018.
Why we inspected
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
The inspection was prompted in part due to concerns received about staffing levels. A decision was made for us to inspect and examine those risks.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe section of this full report.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Agape Annexe is registered to accommodate four people, with learning disabilities and mental health needs; at the time of our inspection there were four people living in the home.
At the last comprehensive inspection in March 2016, the service was rated good. At this unannounced inspection undertaken on 25 April, 3 and 8 May 2018, we found the service remained overall ‘good’.
This inspection report is written in a shorter format because our overall rating of the service has not changed since our last comprehensive inspection.
Some people’s personal rooms and the main bathroom was not visibly clean and some items of furniture required replacing. However, the provider who is also the registered manager had addressed these concerns by the end of the inspection.
Audits to monitor the quality and safety of the service undertaken by the provider required improving to ensure that all rooms in the home where assessed for general decoration and cleanliness on a regular basis.
Staff followed the procedures for safeguarding people from the risks of harm or abuse. Risk management plans were in place to safeguard people's personal safety and manage known environmental risks.
Staffing arrangements met people's individual support needs. The recruitment procedures ensured only suitable staff were employed to work at the service. Medicines were appropriately managed and staff followed infection control procedures to reduce the risks of spreading infection or illness.
Staff had comprehensive induction training and on-going refresher training that was based on following current best practice. Staff supervision and appraisal systems ensured staff had regular opportunities to discuss and evaluate their learning and development needs and their work performance.
Staff supported people to follow a nutritious, varied and balanced diet. The staff supported people to access health appointments as required so that people's continuing healthcare needs were met.
Staff understood the principles of the Mental Capacity Act, 2005 (MCA) and ensured they gained people's consent before providing personal care. People were encouraged to be involved in decisions about their care and support and information was provided for people in line with the requirements of the Accessible Information Standard (AIS).
People had their privacy, dignity and confidentiality maintained at all times. People experienced positive relationships with staff and received care that respected their diversity as staff supported people to maintain relationships with family and friends and make new friends. The care people received from staff was kind, caring and compassionate.
The provider operated an open and transparent culture. Events such as safeguarding matters, accidents and incidents had been reported to the Care Quality Commission (CQC) and other relevant agencies as required. Complaints brought to the provider's attention had been dealt with in accordance with the complaints procedure.
Agape Annexe provides accommodation and personal care for up to four people with a learning disability and mental health needs. At the time of our inspection, the service was providing support to four people.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
People felt safe. Staff had an understanding of abuse and the safeguarding procedures that should be followed to report abuse and people had risk assessments in place to enable them to be as independent as possible.
Effective recruitment processes were in place and followed by the service and there were sufficient numbers of staff available to meet people’s care and support needs
Medicines were stored, handled and administered safely within the service.
Staff members had induction training when joining the service, as well as regular ongoing training.
Staff were well supported by the registered manager and had regular one to one supervisions.
People’s consent was gained before any care was provided and the requirements of the Mental Capacity Act 2005 were met.
People were able to choose the food and drink they wanted and staff supported people with this.
People were supported to access health appointments when necessary.
Staff supported people in a caring manner. They knew the people they were supporting well and understood their requirements for care.
People were involved in their own care planning and were able to contribute to the way in which they were supported.
People’s privacy and dignity was maintained at all times.
People were encouraged to take part in a range of activities and social interests of their choice.
The service had a complaints procedure in place and people knew how to use it.
Quality monitoring systems and processes were used effectively to drive future improvement and identify where action was needed
Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.
Is the service safe?
People who used the service told us that they felt safe. One person told us they would be able to contact someone if they had any concerns about themselves or others. Staff received training in safeguarding vulnerable adults and were aware of their responsibilities for reporting any concerns about the treatment of people.
Care plans and risk assessments were in place which identified any specific risks for people who used the service and the actions staff should take to minimise the risk.
We found that medication was stored and administered safely.
Is the service effective?
People's health and care needs were assessed and plans of care developed according to their needs. Information about things that were important to people and how they wanted to be supported was identified in care plans, which helped staff to provide appropriate care. From our observations and discussions with staff, we concluded that staff had a good knowledge of each person's care needs and preferences. This meant that staff were able to support people effectively.
Is the service caring?
We saw that people were treated with dignity and respect by the staff. People who used the service were relaxed in the presence of staff and responded positively to them. People who used the service told us that they got on well with the staff and we heard staff talk about people in a caring and supportive manner.
Is the service responsive?
We saw that staff were responsive to people's needs. For example, staff understood the importance of checking for any signs that people may need additional reassurance following the recent move of two people to Agape Annexe.
Is the service well-led?
We found that the service was well managed. Managers were involved in the day to day running of the service and discussion with people who used the service confirmed that they had confidence in them.
Contact details for managers were available to people who used the service and staff. One person who used the service said they could contact managers at any time if there was a problem.
We saw that the Provider had purchased appropriate, lockable, filing cabinets for the storage of files which contained sensitive personal information.
We looked at care plans and other information and we saw that this was up-to-date and appropriately structured in the new files.
We saw that the Provider had implemented improved storage facilities for archived information. New retention and destruction arrangements meant sensitive and personal information was managed safely.
We saw how people in the home were encouraged to lead independent lives and spoke to one person who lived at the home and family members. The people who lived in the home told us about their daily activities.
Family members told us they were happy with the care and support provided by Agape Lodge. One family member told us, 'We do try to visit X regularly. He is well looked after.'
We reviewed the record keeping and security and storage arrangements in the home. We were told that care files for the people who lived in the home were kept at Agape Lodge, another home owned and managed by the provider. When we looked at the care plans we found that they were not always up dated routinely following a review of care and support needs.
We looked at the archived records and care plans for people who lived in the home and found that they were not stored securely or confidentially.