- Care home
Agnes Court - Care Home with Nursing Physical Disabilities
We served a warning notice on Leonard Cheshire Disability on 30 July 2026 for failing to meet the regulations related to person-centred care and good governance at Agnes Court - Care Home with Nursing Physical Disabilities.
Assessment report published 7 September 2026
Contents
Ratings
Our view of the service
Assessment dates: 24 June to 15 July 2026
Agnes Court is a nursing home for adults living with physical disabilities, learning disabilities and autism. At the time of the assessment, 23 people were living at the service. We assessed the service against ‘Right Support, Right Care, Right Culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted. We found that people did not always receive care and support in accordance with its principles. People’s needs, preferences, aspirations and outcomes were not reviewed in line with the guidance, and systems and processes did not always ensure person-centred and outcomes-focused care.
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.
People's experience of this service
Where people could not tell us directly about their experiences, we spoke with relatives and carried out observations to understand how people experienced living at the service.
Some people told us they felt happy, safe and enjoyed living at the home, while others and their relatives described concerns about staffing, independence, engagement and opportunities to achieve personal goals.
One person told us, “It’s lovely” and said they felt safe, enjoyed activities and liked the food. Another person said, “I like it, it’s homely… I can’t fault them (staff)”. People spoke positively about the activities coordinator and described enjoying crafts, music, painting and social activities. Relatives told us staff often made efforts to support people’s interests and organise special events, holidays and concerts.
People and relatives described staff as kind, caring and respectful. Relatives used phrases such as, “they’re so lovely”, “the carers are really kind” and said staff knew people well.
However, people and relatives consistently raised concerns that staffing pressures were affecting their experiences. Some people told us they had to wait for support, particularly during evenings and weekends, and some relatives described difficulties finding staff. Relatives also described reduced opportunities for trips, hobbies, physiotherapy and community activities that were important to people. Our observations reflected some of this feedback. Whilst staff responded to people’s immediate care needs, there was limited evidence of proactive engagement outside organised activities. Some people spent prolonged periods without meaningful interaction and some told us they wanted greater independence and choice. Relatives also told us about a lack of consistency in key workers, which impacted relationships and communication.