Agnes Court - Care Home with Nursing Physical Disabilities

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safeguarding.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Although systems were in place to record incidents and share learning, incidents, accidents and near misses were not always recognised, recorded, investigated or used to drive improvement. We found examples where incidents were either not recorded or where evidence of investigation outcomes could not be demonstrated. For example, a bed damaged during a fire drill had not been recorded or investigated, limiting opportunities to review risks and prevent recurrence. This meant the provider could not demonstrate that risks had been reviewed, lessons had been learned, or appropriate action had been taken to prevent similar incidents occurring again, placing people at increased risk of harm.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People's needs were assessed prior to admission and staff worked with community learning disability teams, GPs and other specialists to monitor people's health and wellbeing. Where people attended hospital or moved between services, information was shared appropriately.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.

Leaders did not consistently recognise, report or investigate safeguarding concerns. For example, allegations raised by staff in January 2026 in relation to people’s choice and control, were not treated as a safeguarding concern or formally investigated. Feedback from staff and people during the inspection indicated these practices still occurred on occasions. This meant concerns were not always appropriately addressed, increasing the risk of harm to people and reducing opportunities for learning and improvement. People told us they felt safe living at the service and many relatives spoke positively about the care provided. Staff demonstrated a good understanding of safeguarding responsibilities and were able to explain how they would recognise and report abuse.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff and leaders demonstrated an understanding of the risks associated with people's health and care needs. However, risk assessments were not consistently personalised or detailed enough to ensure staff supported people safely and consistently. Guidance relating to aspiration, oral care, emotional wellbeing, community access and online safety did not always clearly explain how staff should support people safely whilst also supporting positive risk taking. We also found that not all people were not routinely supported to take reasonable risks to increase independence, such as managing their own money. This increased the risk of inconsistent staff practice and limited people's opportunities to develop and maintain independent living skills whilst maintaining their safety.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service had arrangements in place to maintain a safe environment, including fire safety checks. However, these were not always effective in identifying and addressing risks. For example, we saw overgrown vegetation affecting emergency lighting for the safe evacuation of people in the event of a fire and evacuation routes had not been fully assessed for people requiring bed evacuations during the night. A relative told us, “The gardens at the back of [Person’s] room, they don't get maintained, we have to do it ourselves.” Governance systems had not identified or addressed all of these issues prior to the inspection, increasing the risk of harm to people in the event of an emergency.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,

supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Recruitment processes were safe and staff received induction, training and supervision. Records showed staff had completed learning disability and autism training which supported them to understand and respond to people's individual needs.

However, staff had not received specific training regarding cerebral palsy and acquired brain injury despite people living at the service with these conditions. This had not been identified or address by the provider or registered manager prior to the assessment.

Staffing levels were calculated by the provider using a tool based on people’s assessed care and support needs. Staff told us staffing levels were sufficient to meet people’s needs. However, feedback from people, relatives and observations made by the inspectors during the assessment showed staffing deployment was not always effective. Inspectors observed people waiting extended periods of time for support from staff to eat their meals. People and relatives reported difficulties locating staff, people being left unsupervised in communal areas, and delays responding to requests for support. A relative said, “There have been moments when we've had to walk about to find a carer." Another relative told us, “The carers seem to be very, very busy.” This meant the provider could not always be assured that people received timely, safe and responsive support that met their assessed needs.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service was observed to be clean, including clinical areas, and staff used personal protective equipment appropriately when supporting people with their personal care needs. Systems were in place for monitoring infection prevention practices, and we found no concerns regarding cleanliness or infection control during the assessment.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

A recent internal provider quality audit identified overdue reviews of some 'when required' (PRN) protocols and inconsistent guidance to support staff in the administration of medicines. The registered manager told inspectors that PRN protocols were on a list to update, and the deputy manager was in the process of reviewing them. However, improvements were not yet fully embedded and records reviewed during the inspection showed some protocols had not been reviewed since 2024. This meant systems were not always effective in ensuring medicines were managed safely and consistently. People received their medicines from trained staff and we found secure storage arrangements and regular stock checks were in place.