Autumn House Residential Home

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 3 Quality statements within this key question. We found 2 breaches of the legal regulations in relation to consent and meeting nutritional and hydration needs. These breaches were continued breaches in regulation.

People’s needs had not been fully assessed, guidance for staff was not always clear or consistent and failed to contain sufficient detail to enable staff to meet their needs. There was a lack of routine monitoring of peoples care and treatment to achieve positive outcomes. This placed people at risk of harm.

Nationally recognised assessment tools were in place, these were not always being completed correctly or effectively to mitigate risk to people.

Some people received food at the incorrect texture to meet their needs and prevent harm, others received food that was not in line with their personal preferences.

The provider did not demonstrate how they considered best practice guidance for people with dementia.

Consent to care and treatment was not always sought within the law and guidance. The provider had failed to ensure they consistently met their legal requirements to assess people’s capacity to make decisions and where needed make decisions in people’s best interests. The provider, manager and staff failed to demonstrate they had sufficient knowledge and understanding of their legal requirements.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People’s needs had not always been fully assessed. Care plans and other guidance for staff was not always sufficient, clear or consistent to enable them to meet people’s needs. People’s needs were not routinely monitored and at times people’s needs had changed but this had not been reflected in guidance for staff.

Nationally recognised tools had been used, these were not always effective as they sometimes were not completed correctly or in full, this meant they were not effective and failed to reduce risks.

People did not always receive care in line with their assessed needs, we observed people being served food that was at the incorrect consistency and posed a risk to the person’s safety.

Staff were required to take people’s vital signs, such as weight, blood pressure, respiration and oxygen, this was not completed in a way that would effectively identify if a person was becoming unwell. staff were not trained and lacked the knowledge and skills, staff failed to recognise concerns and management failed to complete reviews. This placed people at risk if they became unwell.

Nationally recognised tools were used to assess the risk of accidents or injury to people. However, they were not always effective as they were not always completed accurately, correctly or in full. They did not always recognise people’s current medical conditions. Actions identified by the assessment were not always completed, for example a person’s assessment required them to be weighed weekly, documentation showed they were weighed monthly.

People who had identified risks were not supported in line with current best practice. For example, during our assessment we noted that every person who was at risk of dehydration was assessed as requiring 1500ml of fluid each day. Staff were not aware that people should be assessed by an appropriate medical professional and have individualised fluid level targets.

The majority of people living at the service had dementia. The service was not dementia friendly, there were long, poorly lit narrow corridors with carpets and walls a similar colour. We observed people becoming disoriented and needing assistance, this reduced people’s independence and increased the risk of people falling.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

The provider failed to gain consent from people, assess people’s capacity to consent where needed and to ensure any decisions made where a person was assessed as lacking capacity to consent, was made in the person’s best interest and was the least restrictive option for them.

We identified generic decisions that placed restrictions on people’s freedom of movement we had identified at our previous assessment was still in place. This meant that people were unable to freely access their own rooms and some communal areas of the home, less restrictive options had not been conserved and this impacted on people’s human rights.

Documents showed that people had demonstrated they wished to leave the service, but the local authority had not been informed. This means that the DoLS was unlawful as the condition was not being met.

The service had CCTV in operation, the provider had failed to follow their own policy and had not protected people’s privacy or completed an impact assessment. This impacted on people’s human rights.