Agathah Limited

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

We spoke with relatives of people, and they were generally happy with the support and care provided by the provider. One relative said, “On the whole they are a good company. We have had the odd issue but have managed to resolve them.” Another relative said, “We have good communication with [manager] and we discuss [family members] needs frequently. [Manager] focuses on [family members] needs.” Relatives told us staff were kind. One relative said, “Staff are very helpful and will do anything for us.” Another relative said, “Staff are all nice, polite and caring. They have a nice way about them and I like that.” Relatives were happy their family member’s received support from regular staff. One relative said, “90% of the time we have [staff name] on other occasions we have someone else but it’s usually the same person.”

This service scored 59 (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. Since our last inspection the provider had made some changes to systems and processes to assist them in identifying any trends and patterns and to learn from safety events. For example, an accident and incident audit was in place and although brief, gave a total number of accidents and documented some learning. However, these systems required embedding in to practice to ensure they consistently identify areas of improvement.

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. The provider had developed good working relationships with healthcare professionals to ensure people received timely and appropriate care which met their needs.

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. The provider shared concerns quickly and appropriately. Since our last inspection the provider had updated their safeguarding policy to include important contact details of professional’s staff could speak to if they had concerns anyone was being abused. The registered manager was the safeguarding lead and had started working with staff to ensure they understood the referral process and were able to identify concerns. However, this system required embedding into practice to ensure staff had the skills and knowledge to keep people safe. The registered manager was knowledgeable about the Mental Capacity Act (MCA) 2005. The MCA requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found the service was working within the principles of the MCA.

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. At this inspection we found the provider had made improvements to people’s care plans and risk assessments to better reflect their needs and show how risk had been mitigated. However, we found some conflicting information was documented which could be confusing for staff to follow. We also saw some care plans were not in place to show how specific health needs were managed. The registered manager knew people well and could explain how care was delivered in line with people’s assessed needs. However, documentation was required to reflect this. While improvements were required in the consistency of records, there was no evidence that these issues had an impact on people’s care, safety or outcomes.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Environmental risk assessments were carried out prior to care commencing and at regular intervals. These considered risks in relation to things such as lighting, pets and appliances.

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. Since our last inspection the provider had completed a recruitment process for each staff member to demonstrate their recruitment process had now been followed. Most pre-employment documentation was now in place, and the registered manager was taking action to ensure a full and comprehensive recruitment process was followed. However, these systems had only recently been implemented and required embedding to demonstrate their effectiveness. The registered manager was in the process of recruiting to 3 posts to ensure there were enough staff to meet people’s needs safely.

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 provider had an infection control policy and procedure which guided staff to reduce the risk and spread of infection. Staff had access to personal protective equipment (PPE) and used this as and when required.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning. The provider had taken steps to improve medicine management systems. People who were prescribed medicines on an ‘as and when’ required basis, now had protocols in place for staff to ensure safe administration. Two staff had completed training in the safe administration of medicines; however, some staff were still to complete this training. The registered manager told us this training had been scheduled to take place at the beginning of June 2026. The registered manager was planning to complete checks on all staff every 6 months to ensure they were competent in medicine management and applying their training and knowledge.