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 requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in continued breach of legal regulation in relation to governance at the service.

This service scored 36 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was a poor culture at the service and the risk of a closed culture developing, Staff told us they did not feel able to speak up or report concerns.

Some staff used outdated language to describe people such as bedbound. This can create a culture where people are viewed as a set of tasks rather than individuals. This had not been challenged by leaders.

Staff, people and relatives had not been given sufficient opportunities to feedback on how the service could be improved.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There was inconsistent oversight of the service. The provider had failed to make substantial, sustained improvements to the service.

Some staff told us they did not feel supported or confident in their roles and did not feel confident discussing this with the provider.

The home manager started working at the service during the inspection, they identified some of the failings and shortfalls we found during this inspection and immediately took action to address them. Further members of the leadership team were being recruited.

People did not feel they could speak up and that their voice would be heard.

Documentation showed staff who had spoken up were not protected in line with whistle blowing principles. Some staff told us they did not feel able to speak up in fear of retribution. Documentation showed staff were informed by a manager that they should not contact CQC if they needed to raise concerns. There was a closed culture developing in the service where safety events and safeguarding would not be reported and therefore risks not mitigated.

The recently appointed home manager was aware of this and had introduced systems to encourage staff to speak up by providing various methods, for example, the use of a QR code, that would enable staff to speak up anonymously.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us and documents showed some staff had requested to work flexible hours, we could not be assured the provider considered their requests as there wasn’t any documentation of the outcome or how the decision had been made, this increased the risk of staff being treated inequitably.

There was a diverse workforce, and staff told us, they appreciated working with staff from different cultures.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider failed to ensure staff felt supported and understood their roles and responsibilities. Staff did not receive a robust induction, have regular supervisions or appraisals. This increased the risk of people’s needs not being met as staff may lack the knowledge and skills to support them effectively.

We were not assured the provider effectively supported staff to improve when they had identified staff performance shortfalls or failings. Staff told us they did not receive regular supervisions. There was a lack of documentation to demonstrate action had been taken to support staff to improve and objectives had been set and reviewed.

We were not assured investigations into safety events, grievances and staff performance and conduct were completed robustly. The evidence relied upon was not always available and the outcome was not recorded.

The provider had insufficient oversight of the service; documentation of audits was limited and did not include audits completed by the management team to check compliance with legal regulations.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The home manager had implemented weekly GP visits and a system to report changes in people’s clinical observations however the service had not always identified people’s health had declined or referrals to medical professional were made. For example, a person had become increasingly agitated during personal care, the home had not escalated this to the GP for further assessment.

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 did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Records showed there was a period of time since the previous assessment where staff did not receive mandatory training in a timely way, this included newly appointed staff. At the time of the inspection the shortfall had been resolved, and staff had completed all their essential training. The provider had changed training provider and were using a different electronic system.

The provider did not have adequate oversight of the effectiveness of the training and staff had the correct knowledge and skills to support people safely. The provider was unable to demonstrate they had monitored staff performance and ability.

The newly appointed home manager was aware of this and had implemented systems to ensure they had oversight of staff performance, knowledge and skills, this needed time to fully embed into the service.