Autumn House Residential Home

On this page

• 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 changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of 2 legal regulations in relation to people’s safe care and treatment and safe environment, these were continued breaches from the previous inspection. However, the service had made some improvements and were no longer in breach of legal regulation in relation to safeguarding, staffing, fit and proper persons employed, meeting people’s hydration and nutritional needs and duty of candour.

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.

The learning culture at the service had improved since our last assessment.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff routinely reported and recorded accidents and incidents, the home manager reviewed these and shared learning with the staff. For example, the home manager had recently implemented fall analysis and regular handover meetings. This meant that the risk of similar accidents and incidents could be reduced.

The provider had made improvements and had started establishing relationships with health care partners to develop safe systems of care. Some health care partners were not involved in people’s care, for example people who had life limiting conditions were not being supported by the local hospice. The provider was aware of this prior to the assessment. The home manager was contacting the relevant organisations at the time of the assessment.

People were not involved in the development of their care plan, people and where appropriate their relative’s involvement is important to ensure essential information is shared between services and any risks were known and mitigated. The home manager was aware of this and had an action plan in place to ensure people were fully involved in the development of the care plans.

There had been no new admissions to the service since the last assessment. However, some people returned to the service after being discharged from hospital. The home manager had carried out a full assessment of each person’s needs and noticed where those needs had changed. These changes were shared with health professionals and staff. As a result, the person received safe care that matched their needs.

Staff received safeguarding training and were able to demonstrate their knowledge had improved since the last assessment. Staff were able to describe different types of abuse, how they would recognise abuse maybe occurring and the action they would take in response. The home manager had a robust understanding of abuse and the actions they would take if they suspected abuse. Concerns were shared with relevant organisations in a timely way. This meant people were protected and prompt action would be taken if abuse was suspected.

People told us they felt safe.

The provider did not always work well with people to understand and manage risks. People and their families were not always involved in decisions of how risks to people’s health and wellbeing would be managed. This meant people were not always supported and enabled to do things that mattered to them.

Staff’s knowledge of risks to people had improved, however further improvement was needed to ensure staff had a robust understanding of all the risks associated with people’s bespoke needs, and how to involve people to manage these risks and to lead fulfilled lives.

The provider did not always control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider was aware of this prior to our assessment and had an action plan in place to make the environment safe and meet people’s needs. At the time of the assessment the service was being refurbished. The home manager was working with the local fire service to become compliant with their regulations.

Some people did not have effective personal evacuation plans; this is because the provider failed to accurately assess the risk. The service had not completed fire evacuations using the number of staff that are on shift at night. This meant staff may not be able to effectively evacuate people quickly in an emergency.

The required work that was identified in the service’s water management review, needed to be completed. This meant the risk of people contracting legionella disease was increased. The provider was aware of this prior to our assessment and was in the process of engaging relevant professionals to complete this work.

Some improvements had been made since our last assessment, this included staff training and knowledge of the action they would take in an emergency, such as fire. People’s bedrails had been risk assessed and were secure, heavy furniture was secured to the wall, window restrictors were in place and were robust and there was a new call bell system in use.

The provider did not operate effective and safe recruitment practices to ensure they employed suitable staff, in line with Schedule 3 and their own policy. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Schedule 3, mandates that providers must keep specific information on staff, including employment history and conduct evidence. Some staff’s employment histories were incomplete, and some staff did not have all their previous conduct checked, where they had previously worked with vulnerable people. This meant the provider could not be assured that staff were suitable to work at the service. This increased risk to people. The provider was responsive to our concerns and immediately took action to gain full employment histories for staff employed and to complete risk assessments, where staff had previously been employed to work with vulnerable adults.

Staff knowledge and skills had improved since our last assessment and staff received supervisions in line with the provider’s policy.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Some waste was stored in an unlocked cupboard; however, the home manager took immediate action and resolved our concern.

The aroma in the home had improved since our last assessment, where malodours remained, there were plans to correct this as part of the renovation of the service.

Staff had access to Personal Protective Equipment (PPE) and wore this appropriately. People, relatives and professionals all provided positive feedback in relation to the cleanliness of the home.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Medicines were stored securely and within their recommended temperatures. People continued to be at risk of accidentally being administered medicines they had an allergy to, as their allergy information was not consistently recorded across their records.

Written guidance to support staff administer when required and or variable dose medicines was not always personalised or individualised. This meant staff or other professionals might not have been aware of when these medicines should be administered, and people were at risk of not receiving these when they needed them.

Some people had their medicines administered covertly. Additional safeguards are required before medicines are administered covertly. Some documentation in place supporting these safeguards lacked sufficient detail, and the use of covert medicines had not been reviewed as required in the depravation of liberties documentation. Therefore, we were not assured that the covert administration of medicines was in the best interests of people or that the effectiveness of the medicines was not altered when administered covertly.

The administration of creams as part of personal care was recorded as completed task within the care records system. People’s care plans failed to provide robust information to enable staff to administer creams safely and effectively.

Medical oxygen was prescribed for administration at the care home via oxygen concentrators and medical gas cylinders. Care plans and records were not available to demonstrate that oxygen concentrator manufacturer's cleaning guidance was being followed for the equipment’s' filters. Staff were also unable to provide assurance that expert advice had been sought concerning the storage and signage for the medical gas equipment. We raised our concerns with the home manager and staff during the inspection and they agreed to take further actions to manage the risks.

We observed some improvements since our last assessment such as the use of as required medication with a sedative effect had decreased. Stock levels were correct, and staff no longer routinely updated medicine administration charts themselves.