Agnes House

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

At the beginning of this inspection, there was some confusion regarding the number of people Agnes House could support and whether they offered respite care. We understood this was partly due to the provider having other registered services in the immediate area that worked closely together and there not always being a separation in how they were managed day to day. The provider immediately updated their statement of purpose, a required document which outlines their service provision and confirmed exactly what constituted Agnes House and the services offered. We found the provider shared rotas across more than one registered service which meant it was difficult to establish what staff were working where and whether they had the correct skills for the service they were allocated. The registered manager said they would review this moving forward. We found the provider had governance systems in place, but they were not always robust. For example, recording the outcome of investigations following an incident or ensuring staff training was reviewed as part of the audit process. We found the policies which guided staff on speaking up and reporting concerns were not always updated to ensure they reflected best practice. The provider acted immediately and added a version date to their policies and shared with us the updated whistle blowing and safeguarding policy which included information about the external agencies staff needed to be aware of. We received some mixed feedback from agencies who worked with the service. Some agencies told us they were still waiting for feedback on issues that had been raised. Staff and relatives were positive about the registered manager. Some staff told us the office could be unorganised at times but that the registered manager was supportive and responsive to concerns when raised. Staff told us they enjoyed working for the service and felt people were settled.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager was knowledgeable of the people they supported and talked about the community they and the provider had created. We were told people had become more settled in recent years and a lot of work had been carried out to improve relationships with relatives and ensure people received input from external health and social care professionals. The registered manager explained they did have the capacity to increase the number of people they supported at Agnes House but had decided against this. This was because they felt people preferred the space they currently had and might find it unsettling.

At the beginning of the inspection we reviewed the providers website and their statement of purpose. A statement of purpose is a legal document that describes what a service will do, where they will do it and who they are doing it for. We found some conflicting information which the provider addressed during the inspection process.

The staff team and the registered manager were complimentary of the relationships they had with one another and the provider. Staff told us the provider visited on a regular basis and spent time speaking with them and the people who lived in the home. Several staff told us, the registered manager had supported them with both work and personal issues and they appreciated the support given. Staff told us they received regular supervision.

The registered manager and the provider were open and responsive to any concerns we found and immediate action was taken. For example, policies were updated and discussions were held with the staff team about record keeping. The registered manager involved others in the organisation and sought feedback before making decisions.

Staff told us they were confident speaking up and felt the registered manager would listen and respond to any concerns they raised. We did find some new staff had not been given the tools to know when to speak up and how to speak up outside of the organisation. When we checked the training records, we found some staff had not received a robust induction and the providers polices did not give clear instructions on who to speak to and when. We raised this with the provider who took immediate action to remedy the situation.

The provider had policies in place to support staff to speak up when needed. However, as part of the inspection process we questioned when the policies had last been updated. We looked at the whistle blowing policy and found no reference in the guidance to inform staff members how and when to speak to external agencies. The policy did not sign post people to the local authority or the Care Quality Commission. The provider was responsive to this concern and the whistle blowing policy was updated immediately. The revised version included speaking up internally and to external agencies, who share the responsibility for monitoring services.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff were complimentary of the registered manager but told us the home could be chaotic at times, as the office was not always organised, and they sometimes struggled to find things. Staff also told us some staff did not always do as they were asked which could be frustrating. For example, some staff did not complete their training when requested. Staff told us they followed best practice for adults with learning disabilities and implemented new directives when required.

The provider's governance systems were not always effective. The provider had processes in place, but these did not always highlight areas of concern and confirm action was being taken. For example, the training records highlighted there were a number of staff who needed to refresh their training in key subjects. However, it was unclear what action was being taken. We found improvements were need to the records staff kept. Staff were diligent at completing records. However, more detail was required to confirm what activities people had engaged in and what people had eaten to ensure the guidance was being followed. Although we could see the notes were checked, the issues we found had not been identified. We spoke to other agencies who have visited the service and they told us the provider was not always efficient at providing reassurances actions had been taken following their visits. The registered manager told us actions had been completed so we were unsure if this was a communication issue or whether any tasks remained outstanding.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.