Agnes Court - Care Home with Nursing Physical Disabilities

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 57 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Staff demonstrated a welcoming, warm and respectful culture that reflected aspects of the provider's values. However, improvements were required to ensure the provider's vision and values were consistently embedded into practice. The service was not able to fully demonstrate how people were supported to lead independent and fulfilling lives through personalised care, inclusive communities and the effective use of technology. There was limited assurance that the provider's ambition to support people to live as independently as possible and achieve positive outcomes was fully embedded across the service. This meant the provider could not fully demonstrate that its vision, values and strategic objectives were consistently translated into people's day-to-day experiences.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff described the registered manager as visible, approachable and supportive. Many relatives spoke positively about the registered manager, describing them as approachable, efficient and willing to address concerns. A relative said, “The manager of the home is very efficient and responds to my emails immediately.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they were confident to raise concerns, however, records relating to concerns raised by staff were not always sufficiently detailed to demonstrate how concerns had been investigated, addressed and monitored for effectiveness. Improvements were needed to ensure there was a clear audit trail showing concerns had been resolved and that actions taken had achieved the intended outcome.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff had completed equality, diversity and inclusion training, and leaders demonstrated a commitment to ensuring staff were treated fairly and with respect. We received no concerns from staff in relation to how they were treated by their colleagues and leaders. Processes supported people with protected characteristics, including consideration of reasonable adjustments where required.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were not consistently effective in identifying, assessing and responding to risks. The provider's quality audit identified shortfalls relating to accident and incident reporting, medication management, fire safety, staffing practices, care record reviews, risk assessment reviews and governance oversight, resulting in multiple high-priority actions. For example, accidents and incidents were not always reported appropriately and safeguarding concerns had not always been notified. The audit also found Person of the Day reviews and risk assessment reviews were not fully embedded, meaning leaders could not demonstrate people’s care plans and risk assessments were consistently reviewed and updated to reflect current needs.

During our assessment we found further evidence that governance arrangements had failed to identify shortfalls in care planning, risk management and Mental Capacity Act compliance. Although audits and monitoring systems were in place, they had not identified missing and contradictory information within care plans, the absence of documented risk assessments for known risks, incomplete mental capacity assessments and best interest decisions, or environmental risks relating to fire safety and equipment. Internal quality assurance processes had also failed to identify concerns regarding MCA compliance despite these issues having remained outstanding for a prolonged period. This demonstrated leaders had not always used governance systems effectively to assess, monitor and improve the quality and safety of the service.

Staff and people living at the service spoke positively about leaders and described them as visible and approachable.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

People did not always benefit from effective partnership working that supported them to live full and meaningful lives in their local community. Some care plans identified aspirations around community involvement, developing skills and participating in activities, but there was little evidence of collaboration with local organisations, advocacy services or community groups to help people achieve these outcomes. This meant the provider could not always demonstrate that effective partnership working was being used to help people achieve their goals, increase their independence or maintain meaningful connections within their local communities.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Leaders had not consistently used learning from inspection findings and improvement actions at other locations within the provider group to drive improvement at this service. Although some quality assurance systems were in place, organisational learning was not always effectively shared, embedded or monitored to ensure sustained improvement and better outcomes for people. This meant the provider could not always demonstrate that learning and improvement were embedded across the organisation to proactively improve the quality and safety of care.