Autumn House Residential Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 6 Quality statements within this key question. We found 2 breaches of regulation in relation to notification of other incidents and good governance. These breaches were continued breaches in regulation.

At our last assessment we rated this key question Inadequate. At this assessment the rating has remained inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

There was a poor culture at the service with inconsistent leadership. Staff were not consistently supported to develop their knowledge and understanding of people, to discuss a shared vision or to improve people's lived experiences. Staff did not understand the language used within people’s care plans was sometimes disrespectful and outdated. The service was not being managed well and governance systems in place were not effective. Leaders in the service lacked skills and knowledge and were not empowered to be responsible for all aspects of the service. This lack of oversight had led to poor experiences for people.

The provider failed to ensure they informed Care Quality Commission of notifiable events at the service where they are legally required to do so.

The providers governance systems failed to recognise shortfalls in people’s care and the service. Actions had not been taken to address previous shortfalls that had been identified by stakeholders, professionals and Care Quality Commission

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There was a poor culture at the service.

Systems in place had not identified that some of the training care staff received had not provided staff the with necessary skills to care well for people.

Staff used outdated language to describe people such as bedbound. This can create a culture where people are viewed as a set of tasks rather than individuals. This had not been challenged by leaders.

Staff, people and relatives had not been given sufficient opportunities to feedback on how the service could be improved.

The managers oversight of the quality of care provided and safeguarding processes that needed to be followed was poor.

The manager had not met duty of candour best practice where incidents and accidents had taken place. This included notifying and apologising to people and their loved ones, detailing how the incident occurred and what action was being taken to prevent incidents happening in the future.

The manager had not always reported safeguarding incidents to external partners responsible for investigating. This resulted in a lack of external oversight and created the risk of a closed culture.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for staff who worked for them.

There was a diverse workforce employed at the service. We found the culture was discriminatory towards staff who were employed from overseas on a sponsorship licence. Staff rotas demonstrated overseas workers were working 12-hour shifts, a mixture of days and nights for over 7 days without having a day off. This included being required to work when the service needed additional staff, this was not the case for other staff.

The provider had not ensured that staff had a good work life balance. Some staff worked excess hours and regularly switched between working days and nights. On occasions staff had been found sleeping on shift.

During this assessment we identified 11 breaches of Regulation, of which 10 breaches were continued breaches. The providers systems had not enabled them to make or sustain improvement or to identify they were not meeting the requirements of these fundamental standards.

Areas of concern identified and flagged to the provider at our last assessment and in our last report, persisted and this continued to impact on people’s safety and on staff wellbeing.

The provider had not addressed concerns in relation to the environment placing people at harm. The providers systems had not identified gaps and inconsistencies in records that might alert them to poor quality care provision.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement, and where advice was provided, this was not always implemented within peoples care plans.

The management team told us that they sought medical advice and support from health and social care professionals when people’s needs changed. However, we saw examples where this had not occurred. Including lack of assessment of peoples changed needs when ready to be discharged from hospital back to the home. And lack of seeking medical advice when people’s physical observations, such as blood pressure, and oxygen saturations deteriorated outside the normal range

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people that they supported. In this case people living with dementia.

They had not promoted a culture of learning, best practice, improvement and innovation. Although nationally recognised monitoring tools were being used in people’s care plans, these were not completed correctly, or their findings were not acted on.