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CQC report explained · a residential care home, run by Aegis Care Solutions

Aegis Residential Care

Trees Residential Care Home, 6 Weavers Road, Pontefract, WF8 1QR

Goodpublished 23 December 2023, 2 years ago

Rated Good: inspectors found the service performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People felt safe, staffing levels were sufficient, recruitment checks were carried out and the home was clean. Some PRN medicines protocols were missing, and one moving and handling record lacked sling configuration information; action was taken during the inspection.
Effective?
Good
Care plans were person-centred and regularly reviewed. Staff had training, people were supported to eat and drink enough, and the home worked with healthcare professionals.
Caring?
Good
People were treated with kindness, dignity and respect. Staff knew people well and supported their privacy, independence, views and choices.
Responsive?
Good
Care plans reflected people's needs, histories and preferences. People were supported with communication, activities, relationships, complaints and end of life wishes.
Well-led?
Good
The home had a positive, calm and caring culture, with supportive management and regular meetings. However, audits had not identified some of the shortfalls found by inspectors, so the provider was asked to sustain and embed improvements.
The latest report, explained

What inspectors found, December 2023

Aegis Residential Care is rated Good; inspectors found kind, safe care, but some medicines protocols and quality checks needed improvement.

This was an unannounced inspection. Inspectors visited the home, spoke with people, families and staff, observed care, and reviewed care, medicines, recruitment and management records.

The home was clean and tidy. There were enough trained staff. People said they felt safe and that staff were kind and caring. Care plans were personalised, people's choices were respected, and they were supported with food, activities, healthcare and end of life wishes.

Inspectors found some gaps. Protocols for some medicines taken when needed were missing, and one moving and handling plan did not explain how a sling should be configured. The home's audits had not found these issues. The manager made immediate changes during the inspection.

All five areas were rated Good: safe, effective, caring, responsive and well-led. This was the first inspection since the service was newly registered. The previous provider's rating was Good in 2018.

What inspectors praised

  • Kind and respectful staff

    People told inspectors that staff were kind, respectful and caring. Inspectors observed positive and relaxed interactions.

    “The staff are all very nice and treat you with respect.” from the report

  • Enough trained staff

    Inspectors found enough suitable staff on duty. Staff received training, supervision and checks on their practice.

    “There were sufficient numbers of suitable staff on duty to meet people's needs.” from the report

  • Personalised support

    Care plans included people's needs, life histories, preferences and choices. Plans were reviewed monthly.

    “Care plans were personalised and contained information relating to people's physical, emotional and mental health needs, their life histories and preferences.” from the report

  • Clean home

    The home was clean and hygienic, with a cleaning schedule and regular infection control checks.

    “The home was clean and hygienic throughout and there was a cleaning schedule in place which was followed by staff.” from the report
What inspectors were concerned about

  • Missing PRN medicine protocols

    needs fixing

    Some instructions for medicines taken when needed were missing from medicine records. The manager added checks and reviews to the daily resident review process.

    “Protocols for how these medicines should be administered was missing in the medicine administration record (MAR) chart for some people.” from the report

  • Moving and handling detail

    needs fixing

    One moving and handling risk record did not explain the correct sling configuration. The manager corrected this during the inspection.

    “There was no loop configuration information in place.” from the report

  • Audits did not find shortfalls

    needs fixing

    The home's quality checks did not include checks for PRN protocols or sling configurations and had not identified the issues found by inspectors. The provider was asked to make the improvements lasting.

    “The provider's systems did not always effectively monitor the quality of care provided to drive improvements.” from the report

  • DBS renewal systems

    minor

    Inspectors recommended that the provider review how it renews DBS checks for staff. The provider made immediate changes to its systems and processes.

    “We recommended the provider reviewed its systems and processes for renewing DBS checks for staff” from the report
Questions to ask them, based on this report
  1. 01How do you now check that every person's PRN medicine protocol is present, clear and regularly reviewed?
  2. 02What checks confirm that moving and handling plans include the correct sling configuration for each person?
  3. 03How have you shown that the changes to audits and checks have been sustained since the inspection?
  4. 04How often are staff DBS checks renewed, and how is this monitored?
  5. 05How are people's monthly care plan and end of life care reviews kept up to date?

This was an unannounced inspection covering all five rating areas, the premises and the care provided; it was the first inspection of the newly registered service. This explanation was written from the published report of 23 December 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Aegis Residential Care

3 rated inspections over 8 years: the service has held its Good rating throughout.

  1. December 2023Goodcurrent rating
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Aegis Residential Care →

  2. February 2022Inspected but not rated
    Safe: Inspected but not rated
  3. May 2018Goodstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
  4. January 2016Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
  5. September 2022

    Registered with the Care Quality Commission on 22 September 2022.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

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