We carried out a review of the data available to us about St Agatha's Presbytery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about St Agatha's Presbytery, you can give feedback on this service.
St Agatha's Presbytery is a small care home that provides accommodation, personal care and support to a maximum of two younger people who have a learning disability or autistic spectrum disorder. At the time of the inspection there were two people living at the service.
People’s experience of using this service and what we found
People told us they were happy and liked living at St Agatha's Presbytery. Staff were seen to be kind, caring and respectful of people's needs and people were complimentary about the care and support provided.
People received individualised care and support from staff who knew them well. The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence.
People received individualised care and support in a way that was flexible and responsive to their needs from staff who knew them well. However, we found whilst regular reviews were taking place some aspects of people’s care records had not been updated when significant changes had occurred. We have recommended the provider reviews the systems in place to ensure people’s support plans are fully reflective of people's individual changing needs and wishes.
People were encouraged and supported to engage with a range of healthcare services. Staff understood people's healthcare needs and acted promptly to changes in people's health.
People’s medicines were managed safely and stored securely.
People were protected from the risk of abuse and were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.
People were encouraged and supported to maintain links with the community to help ensure they were not socially isolated. People were encouraged to share their views and people told us they were aware of how to make a complaint.
People were protected by safe recruitment processes. Systems were in place to ensure staff were recruited safely and were suitable support people who might be vulnerable by their circumstances.
People and staff had confidence in the service and told us the service was well managed.
The service was clean, and staff had access to personal protective equipment (PPE)
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was ‘Requires Improvement’ (published on 6 December 2018) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This was a planned inspection based on the previous rating.
Follow up
We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
St Agatha's Presbytery is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is registered to provide personal care and support for up to two young people who have a learning disability or autistic spectrum disorder. The home does not provide nursing care. At the time of the inspection there were two people living at the home.
St Agatha's Presbytery had been developed and designed in line with the values that underpin Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. We found the home followed some of these values and principles. These values relate to people with learning disabilities living at the home being able to live an ordinary life.
St Agatha's Presbytery had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the home. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the home is run.
The home’s quality assurance and governance systems were not always effective or robust. The provider used a variety of systems to monitor the quality and risk at the home. In addition, the home used an external company who provided independent monthly reports on the quality and safety of the care provided. We found the arrangements in place had not identified the concerns we found at this inspection.
Quality assurance systems had failed to identify that the home was not always working within the principles of The Mental Capacity Act 2005 (MCA). For example, records for one person showed access to their money, the internet and their mobile phone was restricted. There were no mental capacity assessments to show the person did not have capacity to manage their own monies, the use of the internet or their mobile phone prior to these decisions having been taken.
The home did not have an effective system in place to assess or to monitor staff training. This meant the registered manager could not be assured staff had the necessary skills and knowledge to meet people’s assessed needs in safe way.
We have made a recommendation in relation to staff training.
Systems and processes did not support the management of the home in protecting people’s right to privacy by preventing the sharing of personal and/or confidential information.
People told us they felt safe living at St Agatha's Presbytery. One person said, “Yes I do feel safe living here.” Another said, “very safe, the staff are good and I can talk to them if I have any concerns. I don’t as it’s all good here.”
People were protected from the risk of harm. People's support plans contained detailed risk assessments and guidance for staff on how to ensure people's safety was maintained, while encouraging people to be as independent as possible.
People received care and support from sufficient numbers of staff to meet their needs. Checks were carried out on staff before they started work to assess their suitability.
People received their medicines when they needed them and in a safe way and people were supported by staff who knew them well. Staff were kind, caring and treated people with dignity and respect. The registered manager and staff understood their roles and responsibilities to keep people safe from harm.
The home was responsive to people's needs. Support plans were personalised and people could make choices about their day to day lives. People were aware of how to make a complaint and felt able to raise concerns if something was not right.
People were supported to maintain a healthy diet. People could choose what they wanted to eat and were involved in the shopping and preparation of their meals. Menus were discussed and planned weekly. People could access the kitchen at any time and were able to help themselves to meals, drinks and snacks.
The home was clean, well maintained, and people were protected from the risk of cross contamination and the spread of infection. Staff had access to personal protective equipment (PPE). Equipment used within the home was regularly serviced to help ensure it remained safe to use. However, we found the home did not have in place suitable arrangement to dispose of items that would be considered healthcare waste.
We have recommended the provider reviews its clinical waste management arrangements.
People, relatives and staff told us they were encouraged to share their views and spoke positively about the leadership of the home. They told us the home was well managed. Staff were motivated and passionate about making a difference to people's lives. The registered manager was aware of their responsibilities in ensuring the Care Quality Commission (CQC) and other agencies were made aware of incidents which affected the safety and welfare of people who used the home.
We identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.