Autumn House Residential Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question inadequate. At this assessment the rating has remained inadequate. This meant people were not safe and were at risk of avoidable harm.

We assessed 7 quality statements within this key question. We identified 7 breaches of the Regulations. People did not receive safe care which met their needs. Safeguarding incidents were not consistently recognised, or action taken to prevent further abuse, staffing, fit and proper persons employed, display of performance assessment, duty of candour, premises and equipment and meeting people’s hydration and nutritional needs. The breach relating to fit and proper persons employed was a new breach. The remaining breaches were continued breaches in regulation and had been identified at the previous inspection. Autumn house has been rated as requires improvement or inadequate within the safe domain for the last 4 consecutive inspections completed by the care quality commission.

The providers safeguarding processes and systems were not effective, we were not assured that the risk of avoidable harm to people had been appropriately mitigated. Risks to people’s health, safety and wellbeing had not always been identified. Guidance for staff on how to avoid risk was sometimes unavailable, contradictory, incorrect and insufficient.

The provider did not ensure people were supported by staff who had the relevant skills, knowledge and training to meet their needs. The providers recruitment practices were not in line with requirements to ensure they followed safe recruitment processes when new staff were employed.

People’s medicines were not always safely managed, people who had their medicines administered covertly did not always have pharmaceutical advice of how to do this safely or the doctors’ consent to administer the medication covertly.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Leaders and staff did not record incidents and accidents consistently. This contributed to lack of investigation to understand how people had been placed at risk of harm and any learning to mitigate future risks to people.

There were repeated incidents where people had communicated their distress through physical harm and verbal agitation towards others. Tools to monitor these risks were not being completed in full or analysed to understand the cause of the distress. Managers and staff did not update peoples risk assessments or care plan following incidents to mitigate the risk of a reoccurrence.

The provider did not work well with health system partners to establish and maintain safe systems of care. Relatives told us they were not involved in developing their family member’s care plan and staff told us that people were not involved in the development of their care plan. People and where appropriate people’s relatives’ involvement is important to ensure essential information is shared between services and any risks were known and mitigated.

Staff had received safeguarding training, and a safeguarding policy was in place. However, staff we spoke to were unable to recall the training or the describe how they would raise concerns.

The manager had failed to identify record and notify the relevant agents about potential safeguarding incidents.

Staff did not always respond well to people in distress, resulting in implementing restrictive practices. One incident recorded how a person in distressed in a communal area had their meal removed by staff and told to leave the room, rather than staff sensitively exploring their distress.

We identified neglectful practice. People who required support to eat, were not always supported.

Staff were not always aware of peoples identified risks. One person required a food to be a certain consistency due to choking risk. Staff didn’t know or provide the person with the safe consistency of food.

People with complex health conditions such as diabetes, epilepsy and heart conditions, did not have care plans to guide staff to identify deteriorating health triggers and what actions to take.

People were not supported to take positive risks. Staff did not support people with opportunities to access the garden space. People were not able to access the community, unless accompanied by a relative.

The concerns we identified relating to the environment at our previous assessment had not been resolved additionally we identified additional concerns during our assessment.

Emergency call bell cords in people’s ensuites had been tied up and were out of reach, this meant people would not be able to call for assistance in an emergency.

The provider had not ensured the environment met fire safety standards. Fire doors had gaps and did not always close fully. Instructions for staff on evacuation in the event of a fire were contradictory. Fire drills had not been carried out with in line with the true numbers of staff on duty during various shifts. We discussed this with the provider and shared our concerns with the local fire service.

The provider had not taken action to minimise environmental risks of injury. They had not fixed heavy furniture to walls. They had not installed tamper proof window restrictions. Bedrails and bumpers were not fitted in line with health and safety requirements placing people at risk of entrapment. Some hot water pipes were exposed, and the provider had not undertaken health and safety requirements in place to prevent legionella developing.

The provider failed to have safe recruitment processes in place. Training and support for staff did not ensure that staff had the skills to keep people safe.

Some staff had begun working with vulnerable people without an enhanced background check (DBS). One such member of staff worked unsupervised caring for 8 people. Following our concerns, the provider implemented a risk assessment and measures to ensure that the member of staff would be supervised.

The provider gave us records of staff having completed mandatory training relevant to their role. However, many we spoke too did not demonstrate they understood training or how to put training into practice. For example, staff were not able to describe how to support people with epilepsy despite receiving training.

The providers records identified that staff did not receive supervision and appraisals in line with their policy. In a 12-month period 25 supervisions / appraisals were due, only 8 had been completed.

We could not be assured staffing levels were safe or sufficient to meet people’s needs. We found multiple different dependency assessments that contradicted each other. Dependency tools help provider judge the number of staff needed and are based on people’s needs, but the dependency levels recorded did not reflect the levels of need detailed in peoples care plans and risk assessments.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Staff kept medications stored securely, however, fridge temperatures were not investigated if they fluctuated to make sure that medicines were kept at the right temperature.

People did not always have their allergies to certain medications documented consistency across records. This placed people at risk of receiving medications that might cause adverse health reactions.

Staff had not always carried out additional consultation and capacity checks where people required medication covertly.