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

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of the legal regulation in relation to consent, this was a continued breach.

This service scored 42 (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 were not always sufficient, clear or consistent to enable them to meet people’s needs. People’s needs were not routinely monitored or reviewed.

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

Some risks to people had not been identified. For example, people who had a mental health condition did not have a risk assessment or a care plan in place. This meant staff did not have the information to enable them to recognise if a person’s mental health was declining. This increased the risk of ill health.

As a result of our feedback, the home manager had employed staff to review people’s assessments and care plans, fully involving people, their family and relevant professionals in the process.

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. This increased the risk of avoidable harm to people.

People who had identified risks were mainly supported in line with current best practice. For example, people who were at risk of dehydration, were assessed by an appropriate medical professional and had individualised fluid targets, this information was available to staff The home manager monitored people’s fluid intake and sought prompt medical advise when required

The service did not always work well across teams and services to support people.

Care plans did not contain sufficient information to enable people to tell their story once, however staff knew people well and worked together to ensure people had consistent support. Staff shared their knowledge with each other and with relevant medical professionals where appropriate.

Staff were able to recognise where people’s needs had changed and took prompt action to involve the relevant professionals.

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

Care plans did not always include key information about people’s medical conditions or how those conditions affected them. As a result, staff did not always have the details they needed to help people manage their health conditions. This made it more difficult to provide safe and effective support. However, staff were able to explain people’s health needs clearly and knew how to help them stay as independent as possible.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

People’s care plans had not been regularly reviewed, this meant that people’s support had not been monitored to ensure its effectiveness. This increased the risk of harm to people.

Staff recorded important information within people’s daily records. People had regular reviews with their clinical team and staff shared the outcome with the team, however people’s care plans were not always updated when changes were made.

When people’s needs began to decline, the home manager worked with them to adjust their care. For example, a person who was experiencing a decline in their mobility was supported to move to a larger room. This ensured the service could continue to meet their needs and reduced the risk of the person not being able to access the communal areas of the home.

The provider failed to gain consent from people and to assess people’s capacity to consent where needed and to ensure any decision 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. This meant we were not assured people’s rights were protected and decisions made on their behalf were done in accordance with the requirements of theMental Capacity Act 2005.

The service had made some improvements since the previous assessment and no longer used CCTV (closed circuit television). People’s freedom of movement within the service had improved as internal locks to their bedroom doors had been removed.