Agape Healthcare Limited was taken out of special measures following improvements since September 2015, but remained Requires Improvement overall due to ongoing breaches of Regulation 17 (governance) and Regulation 19 (fit and proper persons), incomplete records, and the absence of a registered manager since September 2014. The service was rated Good for caring, with people reporting kind, consistent and respectful staff, but systemic weaknesses in training, record-keeping, risk assessment and leadership oversight persisted across all other key questions.
Concerns (8)
criticalGovernance: “The lack of effective oversight and governance was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
criticalStaff competency: “Recruitment procedures did not establish or were operated effectively to ensure that people employed were of good character, have the qualifications, competence, skills and experience necessary.”
criticalLeadership: “There had been no registered manager in place since September 2014.”
moderateStaff training: “There were no robust training processes to ensure staff regularly refreshed their knowledge.”
moderateRecord keeping: “Care staff did not record the times they attended or left calls so the manager was unable to identify if people were receiving their calls on time.”
moderateCare planning: “This information was not recorded in people's care plans for other members of staff.”
moderateIncident learning: “Although the manager had taken action when a person raised a specific concern we noted that the person had raised the same concern on several occasions before action was taken.”
minorSupervision / appraisal: “There were no processes in place however to ensure staff would meet regularly with the manager or record the outcomes of these meetings.”
Strengths
· People said staff were caring, kind and considerate, and respected their wishes and dignity.
· Manager introduced a weekly process to seek people's views and ensure regular contact.
· People were supported by consistent, regular staff enabling positive relationships.
· Manager was readily contactable and responsive to staff and service users.
· Provider improved involvement of people in developing their care plans.
Quality-Statement breakdown (8)
safe: Risk assessment guidance for staff was sometimes incomplete or contradictory.Requires improvement
safe: Recruitment checks did not robustly demonstrate staff were fit and proper persons (breach of Regulation 19).Requires improvement
effective: Staff induction and training records were not robust or consistently maintained.Requires improvement
effective: Systems to monitor if people were at risk of not eating and drinking sufficient amounts were not robust.Requires improvement
caring: Staff were respectful, considerate and promoted people's privacy and dignity.Good
responsive: Care records remained incomplete and did not always capture people's preferences and lifestyle choices.Requires improvement
well-led: No registered manager in post since September 2014; breach of registration condition.Requires improvement
well-led: Quality monitoring processes were ineffective; governance breach of Regulation 17.Requires improvement
Agape Healthcare Limited was rated Requires Improvement overall following a December 2014 inspection, with Inadequate well-led due to absent registered manager, ineffective quality monitoring, and unresolved breaches from a prior inspection. Multiple regulatory breaches were identified covering recruitment, staffing competency, consent/Mental Capacity Act, and quality assurance, though caring was rated Good reflecting consistent, person-centred staff relationships.
Concerns (12)
criticalSafeguarding: “Two other staff we spoke with were not clear about who they could report safeguarding concerns to outside of the provider's organisation.”
criticalMedication management: “Records did not contain clear information to enable staff to ensure medicines were administered safely.”
criticalStaff training: “The provider did not ensure that staff received an induction or training to address gaps identified in their skills and knowledge.”
criticalConsent / capacity: “The manager was unable to explain the principles of the Mental Capacity Act 2005 or clarify the provider's policy for assessing if a person lacked capacity.”
criticalGovernance: “The provider did not have a robust system to review the quality of the service...only had time to conduct a quality check of one person's daily notes.”
criticalLeadership: “The provider had not made arrangements to ensure the service had a registered manager.”
moderateRecord keeping: “Information required to ensure people received care which kept them safe was not always carried forward when assessments were updated.”
moderateCare planning: “No changes had been made to their care plan to reflect that the person was less able to be involved in their personal care.”
moderateStaff competency: “The provider had failed to ensure that staff had access to all the guidance and information they needed to ensure people were kept safe from the risk of harm.”
moderateSupervision / appraisal: “The manager told us that they had only conducted a supervision meeting with one member of staff since our last inspection.”
moderateIncident learning: “The provider did not have a system to record concerns or learn from untoward incidences.”
minorComplaints handling: “Several people told us that the manager did not always respond promptly to concerns raised.”
Strengths
· People were consistently supported by the same staff members, enabling meaningful relationships to develop.
· Staff knew people's cultural, religious and language preferences and were matched accordingly.
· People reported feeling safe and that staff were attentive and responsive to their individual needs.
· The provider maintained a pool of bank care staff to ensure sufficient staffing levels.
· Staff demonstrated knowledge of people's preferences, likes and dislikes, delivering care in line with wishes.
Quality-Statement breakdown (16)
safe: Recruitment and employment checksRequires improvement
safe: Medication management and guidanceRequires improvement
safe: Risk assessments and care record informationRequires improvement
safe: Staffing levelsGood
effective: Staff training and inductionRequires improvement
Agape Healthcare Limited was rated Inadequate overall and placed in Special Measures following a September 2015 inspection, with multiple breaches of the Health and Social Care Act 2008 Regulations including failures in recruitment, medication management, safeguarding notifications, consent/capacity, staff training, and governance. Required improvements from the previous December 2014 inspection had not been made, and the service had operated without a registered manager since September 2014.
Concerns (12)
criticalSafeguarding: “the manager was not aware of their requirement to notify the local safeguarding authority when they thought people were at risk of harm.”
criticalMedication management: “there was no information for staff about people's medications or any risks they presented.”
criticalStaff training: “There was no formal induction process for new members of staff when they started working at the service.”
criticalStaff competency: “The manager had not always checked if new staff had a criminal background before they were employed. This was in breach of Regulation 19.”
criticalGovernance: “The provider did not have robust or effective processes in place for monitoring and improving the quality of the care people received.”
criticalLeadership: “There had been no registered manager in place since September 2014. Since that time one of the company directors had been managing the service.”
criticalConsent / capacity: “The provider had not conducted assessments when people were thought to lack mental capacity. This was in breach of Regulation 11.”
moderateCare planning: “Most care records sampled were incomplete and did not contain information about people's lives and experiences.”
moderateRecord keeping: “Records were not maintained when people needed support to receive the appropriate nutrition to keep them well.”
moderateSupervision / appraisal: “there was no formal programme to hold meetings or individual supervisions with staff, in order to identify how they could best improve the care people received.”
moderateIncident learning: “There was no system to review serious incidents when people were put at the risk of harm in order to protect other people from similar risks.”
moderatePerson-centred care: “Two people we spoke with told us their care plans had not been updated to reflect their changing needs.”
Strengths
· People said that staff were caring, kind and considerate when providing personal care.
· People confirmed they were always supported by the number of staff identified as necessary in their care plans.
· Staff were consistently assigned to specific individuals, providing familiarity and continuity.
· People felt safe with care staff and said staff knew how to keep them safe.
· The manager was described as friendly and readily contactable by both staff and people using the service.
Quality-Statement breakdown (20)
safe: Recruitment and pre-employment checksInadequate
safe: Risk assessment and managementInadequate
safe: Medication managementInadequate
safe: Safeguarding notificationsInadequate
safe: Staffing levels and consistencyGood
effective: Mental Capacity Act compliance and consentInadequate
effective: Staff training and inductionRequires improvement
effective: Nutrition and hydration monitoringRequires improvement
Agape Healthcare Limited was rated Good overall following a February 2017 announced inspection, with four of five key questions rated Good. The Well-Led domain required improvement due to incomplete quality audit systems, inconsistent record keeping, failure to display inspection ratings promptly, and absence of formal supervision and spot-check programmes.
Concerns (6)
moderateRecord keeping: “Checks had not always been effective and had failed to identify when care staff regularly left calls early or records were not completed fully.”
moderateGovernance: “There was still no formal programme in place to ensure these checks would take place as planned.”
minorMedication management: “Details of people's creams were now in their care records but had not been included in specific medication records for staff. This did not make them easy to find and refer to.”
minorCare planning: “Although there was guidance for how staff were to meet people's specific needs, there was no general information about the conditions people had or how they could impact upon them.”
minorSupervision / appraisal: “Although staff received formal supervisions there were no formal plans to ensure these would be conducted consistently.”
minorStaff training: “Staff had not had refresher training in some aspects of people's specific conditions for several years.”
Strengths
· People felt safe and trusted staff; safeguarding knowledge and body map recording in place
· Robust recruitment checks including DBS and references conducted for all staff
· Staff completed the Care Certificate and were knowledgeable about individuals' specific care needs
· People were supported in line with the Mental Capacity Act 2005 and their wishes were respected
· Consistent staffing enabled staff to know people's preferences and deliver person-centred care
Agape Healthcare Limited, a small domiciliary care agency supporting 5 people in Birmingham, was rated Good overall at its August 2019 inspection, with all five key questions rated Good. The service demonstrated consistent, person-centred care, effective safeguarding and medicines management, and meaningful improvement in governance since the previous inspection where well-led had been rated Requires Improvement.
Strengths
· People were supported by consistent, caring staff who knew their individual preferences, life histories and communication needs.
· Robust recruitment process including DBS checks and satisfactory references prior to employment.
· Medicines managed safely with regular MAR audits and staff competency checks.
· Detailed risk assessments in place, regularly reviewed and updated to reflect changes in care needs.
· Staff received regular supervision, annual appraisals, induction including Care Certificate, and ongoing training.
Quality-Statement breakdown (25)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
This focused follow-up inspection of Agape Healthcare Limited found that the provider had taken meaningful steps to address breaches identified in April 2016, including improving care planning, staff training, supervision, and medication records. However, a 'Requires Improvement' rating was maintained for Well-Led due to the absence of a coordinated improvement plan, incomplete information sharing between managers, and inconsistent record-keeping practices.
Concerns (5)
moderateGovernance: “We noted there was no overall plan to ensure that actions and resources were coordinated effectively.”
moderateLeadership: “they had not shared details of our warning notice with the new manager to ensure their actions to improve the service addressed the concerns identified”
minorRecord keeping: “staff had not always accurately recorded the time they attended calls in people's records”
minorMedication management: “further information was required to support people to apply creams they might require. This was being addressed.”
minorGovernance: “in some instances checks were not always planned ahead to make sure they would be completed systematically.”
Strengths
· New manager reviewed and updated care plans with people's expressed preferences and risk minimisation guidance.
· Structured staff training programme introduced including weekly refresher sessions.
· Regular supervisions introduced for care staff, described by staff as 'Very helpful, really good.'
· Weekly telephone calls introduced to seek service users' views, with positive feedback received.
· Medication records updated with detailed guidance for staff; people confirmed calls now arrive on time.
caring: Consistency of care staff and relationship buildingGood
caring: Person-centred and culturally sensitive careGood
responsive: Responding to changing care needsRequires improvement
responsive: Complaints and concerns handlingRequires improvement
well-led: Quality monitoring systemsInadequate
well-led: Registered manager in postInadequate
well-led: Staff supervision and appraisalInadequate
well-led: Response to previous CQC inspection findingsInadequate
effective: Staff support for people's needs in practiceGood
caring: Staff attitude and relationships with peopleGood
caring: Dignity and privacyGood
caring: Formal engagement and involvement in care planningRequires improvement
responsive: Person-centred care and responsiveness to preferencesGood
responsive: Complaints handling and feedback processesRequires improvement
responsive: Regular contact and engagement with people using the serviceRequires improvement
well-led: Quality monitoring and governance systemsInadequate