Autumn Lodge

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 good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 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.

Accidents and incidents were robustly recorded. Staff and people were encouraged and supported to raise concerns. Staff were confident concerns would be followed up and investigated fully. Any lessons learnt were shared across the staff team, through handovers, meetings and supervisions. The home manager had good oversight of any incidents and monitored them regularly to ensure any patterns or trends were identified and addressed. Where things had gone wrong, this was addressed in an open way with a focus on learning rather than blame.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Staff and management had a good relationship with external professionals, which supported continuity of care and safe transitions when people needed support from external services, for example being admitted to hospital. Professionals told us, without exception, that staff worked with them well to ensure safe delivery of care. Staff knew how to recognise when people may need support from external services. They worked with professionals to keep people safe. One staff member told us, “We have good connections with [community services] and refer people when they need extra support.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People using the service and their relatives consistently told us they felt safe and were satisfied with the care provided. One relative said, “I’ve got no concerns when I leave here, [person] is very safe.” A person told us, “Yes, yes, very safe here all the time.”

Staff demonstrated a clear understanding of their responsibilities in safeguarding people from abuse, and neglect and felt confident in raising concerns. One staff member said, “I would report any issues without delay. I’m confident that things are acted on here. [Management] are very good.”

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that, where required, mental capacity assessments were in place to safeguard people’s rights in relation to decisions about any risks and DoLS applications had been submitted and were managed appropriately.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks were assessed and minimised as much as possible. People’s care plans contained guidance for staff on how to minimise risks to people. Where appropriate, staff supported people to take positive risks to promote their independence. One staff member told us, “Risk shouldn’t mean restriction, we try to keep people doing what they can for as long as they can.”

Risks that were identified were managed and measures put in place to reduce them. For example, when people were at risk of falling equipment such as sensor mats were provided to alert staff should a person start to mobilise.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had developed a system to ensure each major area of health and safety in the home was safe and compliant. This included regular fire safety checks, water checks and servicing of lifting equipment. People had personal emergency evacuation plans (PEEPs) which were individual to their needs. These were readily available and staff demonstrated good knowledge of them. Management used a Health and Safety Compliance Grid to ensure robust environment checks were completed and any issues were addressed quickly.

The home was clean and free from malodours and designed to be dementia friendly. Refurbishments were ongoing to ensure the home remained accessible. People’s rooms were easily identifiable with personalised items. There was clear signage throughout which helped people to navigate around the home. The provider had worked with a local artist to decorate the corridors with pictures of the local area which encouraged people to reminisce whilst moving around the building.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.There was a stable workforce, with many staff having worked at the home for a considerable period.

People and their relatives told us there were sufficient staff and our observations confirmed this. One relative said, “I think there are enough staff, there are a lot of them, and they are all very caring.” The staff rota was completed well in advance to ensure the right mix of staff with relevant skills were available.

Throughout the inspection, we saw staff responding to people promptly, and they had time for meaningful interactions without rushing. Staff spoke positively about the training opportunities available. One staff member said, “Most of it is done in-house which I think is quite rare. Training suits my role.”

The provider had robust recruitment systems in place. Background checks, such as Disclosure and Barring Service (DBS) checks, were completed to ensure staff were safe and suitable to work with people using the service.

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 was clean and tidy. There was a designated housekeeping team who used cleaning schedules to ensure people’s rooms and communal areas were maintained to a high standard. The home had been refurbished which supported good infection control. One staff member told us, “There used to be carpets, and they were difficult to keep clean. Now it’s so much easier to keep the floors nice and hygienic.” Staff wore personal protective equipment (PPE) appropriately and there was a plentiful supply. Infection control policies were up to date and relevant for the service.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines safely and in line with their needs and wishes. Staff had received suitable training to administer medicines, and they had regular competency checks to ensure they remained safe to do so. The provider had an electronic medicines administration record (eMAR) system which supported accurate record keeping. Audits were completed regularly to ensure any errors were addressed quickly. The provider had also invested in equipment to ensure storage of medicines was safe, this included an air conditioning unit to manage the temperature in the dedicated medicines room.

Staff worked in line with a national initiative in relation to medicines. This included the use of the ‘Self-Care Toolkit’. This enabled staff, and where appropriate people, to treat minor ailments within the service with homely remedies, rather than needing a visit to the GP. There was a robust policy in place to support this.