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 changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes

The service was in continued breach of legal regulation in relation to consent.

This service scored 33 (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 make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.

People’s needs had not always been fully assessed. Care records were not always sufficient, clear or consistent to enable staff to meet people’s needs. People’s needs were not routinely monitored or reviewed.

Nationally recognised tools had not been used effectively as they were not completed correctly or in full, which meant they failed to reduce risks to people. For example, where people’s mobility had declined, tools were not updated and did not reflect an increased risk in falls, this placed people at risk of injury.

people with mental health conditions did not always have risk assessments and care plans. Where these were in place, they were generic and lacked detail to help staff support people’s emotional wellbeing, identify deterioration, and take appropriate action. Some risk assessments had been updated and these were clear and provided staff with the information they required to meet people’s needs.

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.

People who had identified risks were not always supported in line with current best practice. For example, people’s health was not monitored following safety events, this increased the risk of people not receiving medical treatment in a timely way.

We were not assured people’s nutritional needs were being met, people had lost over 10% of their weight since the previous inspection, most people were weighed regularly, however their weight was not reviewed. This placed people at risk of malnutrition.

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.

The culture of sharing information had not improved since the previous inspection; staff told us they were not provided with opportunities to share information with each other. For example, staff meetings and handovers. This meant people were at increased risk of harm from inconsistent care.

The service did not always share information with health care partners, for example, multiple records demonstrated people had lost over 10% of their body weight since the previous inspection. People’s GPs had not been informed, increasing the risk to people’s health needs being unidentified, medical conditions deteriorating and people not receiving effective treatment.

The newly appointed home manager identified the risk and took appropriate immediate action.

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.

Improvements had not been made since the previous inspection.

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. For example, a person who had seizures, did not have their monitoring needs assessed, this increased the risk of the person not receiving prompt medical treatment.

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

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, increasing the risk of people not receiving support in line with their assessed needs.

People being cared for in bed were being assessed for suitable equipment to enable them to get out of bed, this would enable people to access the communal areas of the home and support their wellbeing.

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 the Mental Capacity Act 2005.

Some decisions had been made without a mental capacity assessment being completed, this indicated staff had not assumed the person had the capacity to make the decision in line with the mental capacity act code of practice. This increased the risk of restricted practice and people being deprived of their liberty.

Documents showed multiple decisions were made at the same time and combined with other decisions and there was no evidence the person had been supported to understand the decision being made. This meant people were not always given the opportunity to show they had capacity to understand the risks in relation to a decision, increasing the risk of decisions being made on their behalf unnecessarily .

Where people were deemed to lack capacity, relatives were not included in deciding the least restrictive way to manage any risk. This increased the risk of people not being supported in their preferred way.