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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm

The service was in continued breach of the legal regulation in relation to safe care and treatment. The service was no longer in breach of the legal regulation in relation to the safety of the environment, although we did identify some shortfalls and the improvements needed to be embedded into the service and the improvements maintained.

This service scored 38 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff did not always document or report safety events. Where safety events had been reported the provider had not reviewed these or shared lessons learnt with the team. This increased the risk of harm, however the majority of incidents had not had a significant impact on people’s health and wellbeing. Following the inspection the newly recruited home manager implemented new processes to analyse safety events, share learning with the team to prevent similar events occurring, this needed to be embedded into the service and maintained.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

The provider did not provide us with information to demonstrate that the service shared information with the incoming provider when people moved between services, this increased the risk to people’s health and wellbeing as the incoming provider did not have details of health system partners involved in the person’s care and did not know the person’s essential health and well being needs and how these should be met. For example 1 person transferred from the service to a hospital, the hospital was unaware of safeguards in place to protect the person and therefore the person was not protected from abuse.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Where deprivation of liberty safeguards had been approved, some approvals were subject to conditions, the service failed to ensure these conditions were met, for example a person cared for in bed, had a condition to have regular interaction with staff, records showed the only interaction they had with staff was task based care, apart from 1 occasion on their birthday.

Although staff received safeguarding training and were able to demonstrate they had maintained some knowledge since the last inspection, neglect was not always recognised and reported to the local authority or the Care Quality Commission (CQC) as required. This meant people were not always protected from harm . The home manager, who started working at the service during our inspection, was responsive to our concerns and implemented systems to ensure neglect was identified, reported and risk of similar further incidents mitigated, this was being embedded into the service and improvements sustained.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider failed to effectively identify risks to people. For example, we observed staff supporting a person with reduced mobility that effected their balance to go outside using a wheelchair, to get outside staff had to push the wheelchair over a raised fresh hold, this risk had not been considered, and the person was not advised to wear a lap belt, this increased the risk of harm. People’s care plans did not contain clear information to enable staff effectively manage risk. This meant people were at increased risk of harm and inconsistent care.

Staff sometimes failed to support people accordance with their assessed needs. For example, we observed 1 person who was assessed as requiring a modified diet, had the incorrect food consistency, this caused them to cough for a prolonged period of time, , this increased the risk of the person developing aspirational phenomena.

people or their relatives had not been involved in identifying risks or how these were managed, increasing the likelihood of harm, due to risks not being managed in the persons preferred way and risks known to the person not being shared.

The provider confirmed following the inspection that people’s care plans had been reviewed and updated

The home manager, who started working at the service during our inspection, was responsive to our concerns and was in the process of reviewing risks with people and their relatives.

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

At the time of the assessment the service was being refurbished, to make improvements and to ensure the service was safe and could effectively meet peoples needs. The home manager was working with the local fire service to become compliant with their regulations. Some of the actions identified in the services fire risk assessment had not been completed and there was no timeframe for completion. Fire alarm checks were not always completed as required. The service had completed fire evacuations using the number of staff that are on duty at night, but the evacuation relied on other members of staff entering the building, which would be unsafe. This meant staff may not be able to evacuate people quickly in an emergency.

Portable appliance testing and gas safety certificates were not in place; this increased the risk of harm to people from using unsafe electrical appliances, The provider was responsive to our concern and arranged for the portable appliance test to be completed.

Some improvements had been sustained since our previous inspection, for example, people’s bedrails had been risk assessed and were secure, heavy furniture was secured to the wall, window restrictors were appropriately in place and there was a new call bell system in use.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support,supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The provider did not operate effective and safe recruitment practices to ensure they employed suitable staff, in line with relevant legislation and their own policy. Guidance states providers must keep specific information on staff, including employment history and conduct evidence. Some staff employment histories and their place of prior employment references were contradictory. This meant the provider could not be assured that staff were suitable to work with vulnerable people. This increased risk to people. The provider was responsive to our concerns and immediately took action to ensure staff’s employment histories were accurate.

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. For example, staff had received food modification training, however we observed 3 separate safety events where people were given food that was not modified in accordance with their assessed need.

During our inspection we observed a lack of staff which impacted on the care people received, including meaningful leisure time and emotional support. People spent the majority of time either in their bedrooms or sitting in the lounge with minimal engagement from staff.

Records showed staff had not received regular supervision and appraisals, this meant staff performance and conduct was not regularly discussed and increased the risk of people receiving poor care.

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.

The home had no malodours and was visibly clean. Staff had access to cleaning products, and these were stored safely. The home was being renovated and the completed areas of the home were freshly decorated, had safe flooring and good quality furniture that could be safely cleaned.

Staff did not always change their personal protective equipment between tasks; however, the home manager took immediate action and resolved our concern.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. 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.

Since our last inspection the provider had migrated their medicines administration records from paper to an electronic system. However, during this change, information about how people preferred to receive their medicines and guidance to support staff to administer when required and or variable dose medicines had not been transferred to the electronic records. This meant people were at risk of not receiving medicines when they needed them.

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

Oxygen was prescribed at the care home using concentrators and gas cylinders. However, records did not show the manufacturer’s cleaning instructions for the concentrator filters were being followed. This issue had been raised at the previous inspection, and we were assured action would be taken. At this inspection, we raised the concern again, and following the inspection, the service provided documents showing that cleaning was scheduled and recorded as required.

Person specific fire risks, for example the use of creams administered when delivering personal care and the use of oxygen were summarised in the evacuation folder for the care home. Medicines were stored securely and within their recommended temperatures.

The administration of creams as part of personal care was recorded as completed tasks within the care records system. Since the previous inspection additional information was now kept with people's creams to support the administration of these creams.