St Agnes Retirement Home

Updated 1 July 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was conducted by two inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

St Agnes Retirement Home is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement dependent on their registration with us. St Agnes Retirement Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with eight people living at the service and four relatives. We spoke with seven staff members which included the registered manager. We reviewed six people’s care records. We looked at a variety of records relating to the management of the service, including policies and procedures and audits.

Updated 1 July 2022

About the service

St Agnes Retirement Home is a residential care home providing personal care for up to 26 older people. At the time of our inspection there were 18 people living at the home. The service is across two floors. On the ground floor there is a lounge, additional quiet lounge and a dining room with level access to the garden. Bedrooms are situated on the ground and first floors

People’s experience of using this service and what we found

The service had made improvements to ensure people had meaningful activities to engage in. Staff supported people to access the local community and maintain relationships with friends and family.

We made a recommendation about governance systems as further developments were needed. This was to ensure all areas were identified where actions were required and incorporated into the service’s improvement plan. For example, in the accuracy and wording of care plans, how feedback information was gathered and in the personalisation of end of life care plans.

The home was clean and tidy. People enjoyed their individual rooms and the outdoor space at the home. There was a good atmosphere where people were listened to and respected.

People were supported well with their nutrition, hydration and healthcare needs. People and relatives felt comfortable in raising any concerns or complaints and actions were taken. Staff were well trained and skilled in their role. Staff knew people well and had developed positive relationships with people.

There were good systems of communications within the staff team and with relatives. People’s opinions and feedback was sought. The management team were open, honest and approachable.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The provider had completed an action plan after a comprehensive inspection (published 19 November 2019) to show what they would do and by when to improve in relation to the breaches of regulation found. The last rating for this service was requires improvement (published 11 February 2021) where improvements had been demonstrated.

At this inspection we found further improvements had been made and the provider was no longer in breach of Regulation 9 (Person-Centred Care).

At our last comprehensive inspection (published 19 November 2019) we recommended that the provider reviewed published guidance about best practice in relation to exploring and recording people's end of life care preferences. At this inspection we found improvements had been made but further development was still required to ensure they were personalised.

Why we inspected

This inspection was carried out to follow up on actions we told the provider to take at previous inspections.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for St Agnes Retirement Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.