Autumn House Residential Home

On this page

• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. The provider and the management team had changed since our last assessment; they were in the process of addressing the failings we found at our previous assessment.

The service was in breach of the legal regulation in relation to governance at the service.This was a continued breach in regulation, the provider had made improvements and was no longer in breach of failing to report incidents and displaying rating certificates.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The culture of the service had improved since our last assessment. Staff had received additional training and were no longer using outdated language. We observed staff spending time with people and they knew them as individuals. This was being embedded into the service to ensure improvements could be sustained.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider and the management team had changed since our previous assessment. The current home manager was an expert in their field and shared their knowledge and skills with the team. This had enabled the home manager to start to make the required improvements, and they had begun to embed these practices.

The provider and the home manager were aware of the improvements that needed to be made and had a robust action plan in place. The provider had ensured that resources were available to make these improvements.

The provider had not updated the complaints policy since the previous assessment, and this was not robust. However, staff were able to describe the action they would take if they had any concerns and told us they felt able to inform the home manager. This was being embedded into practice at the time of the assessment and more time was needed to ensure the improvement was sustained.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a diverse workforce employed at the service, the culture had improved since our previous assessment and staff were treated fairly. Staff told us they felt supported by the home manager.

The provider was aware of most of the shortfalls we identified during the assessment, however time was needed to rectify these failings, implement the improvements, embed these into the service and sustain improvements.

People needed up to date assessments and their care plans needed a comprehensive review, to ensure staff had sufficient information to meet people’s needs and provide safe care.

Some audits were not in place or had actions that had not been completed; for example, care plan and risk assessment audits were not in place and environmental audits were completed but actions had not been completed. This was largely due to the provider and home manager implementing changes to the service. This increased the possibility of new risks not being identified in a timely way.

The service was actively recruiting members of the management team and had appointed staff to some roles. Time was needed to fully induct new staff into their roles and for them to embed improvements into the service.

Staff were able to describe their responsibilities, however further training was required to ensure they had the knowledge and skills to embed and sustain the improvements.

The service did not always work in partnership with health and social care professionals. The provider and home manager were aware of this prior to the assessment and were making connections with health and social care professionals to establish robust working relationships.

The home manager had implemented weekly GP visits and a system to report changes in people’s clinical observations.

The home manager was making connections with the local community to ensure people had access to the community facilities to enhance their wellbeing.

The provider focused on continuous learning, innovation and improvement across the service, however further improvement was needed to ensure the service delivered equity of experience, outcome, quality of life for people and could actively contribute to safe, effective practice and research.

The culture of learning, best practice and innovation had improved since the previous assessment, however, further work was required and time was needed to embed this into practice. The home manager was aware of this and was encouraging the team to develop their knowledge, skills, experience and confidence with supporting people’s bespoke needs.