A residential facility in Oxfordshire has received an official warning from the health and social care regulator following an inspection that revealed significant regulatory failures.
Agnes Court, which provides care for individuals with physical disabilities, was served the formal notice on July 30.
The inspection by the Care Quality Commission took place between June 24 and July 15 of this year.
The establishment, located on Warwick Road in Banbury, operates as a specialist nursing home catering to adults affected by physical disabilities, learning disabilities and autism spectrum conditions.
Regulatory assessors evaluated whether the operator ensured that the 23 residents received dignified treatment, were treated equally, maintained their independence, had access to meaningful choices and could participate in community life.
The warning notice specifically addressed shortcomings in meeting requirements for person-centred support and effective governance at the facility.
Inspectors identified four separate regulatory breaches covering safeguarding procedures, consent protocols, person-centred care standards and governance arrangements.
One resident informed investigators the facility was pleasant and reported feeling secure, participating in activities and enjoying the cuisine.
Another individual described the environment as comfortable and welcoming.
Despite these positive individual comments, both residents and family members repeatedly highlighted that workforce pressures were negatively impacting daily experiences at the home.
The inspection concluded that all five assessed domains demanded improvement, including safety standards, effectiveness of care delivery, the caring approach, responsiveness to needs and leadership quality.
Concerns raised by employees in January 2026 regarding residents’ autonomy and control were not classified as safeguarding matters nor subjected to formal investigation procedures.
Certain relatives reported they had not been consulted during reviews of their family member’s care arrangements.
Multiple family members disclosed they had never been invited to express satisfaction with the support provided.
Investigators also discovered instances where residents were not consistently afforded privacy, external excursions occurred infrequently and chances to pursue personal interests had diminished following reductions in staffing levels.
The report further highlighted that individuals and families described waiting periods when assistance was required.
Investigators established that employees deactivated call bell systems to prevent emergency activation, resulting in residents experiencing distress and extended waits for help.
Some residents spent considerable durations without meaningful engagement with staff.
Several individuals expressed desires for increased self-determination and variety in daily life, with a number experiencing inconsistent support from key workers and missing established relationships and communication channels.
A representative for Leonard Cheshire, the organisation operating the facility, acknowledged the concerns raised by the regulator, noting that numerous issues had already been identified through the charity’s own internal monitoring processes.
A thorough improvement programme is currently being implemented to enhance conditions for residents at Agnes Court, incorporating additional supervision and support from senior personnel and quality specialists alongside supplementary training provisions.
Regular communications will be provided to residents and their families as progress continues across all relevant areas.