Autumn House Residential Home

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• 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

The service was not safe and is inadequate. We identified 5 breaches of the legal regulations. People did not receive safe care and care plans and risk assessments to support safe and consistent care were not always in place, reviewed or updated when needed. There was no evidence of a positive learning culture within the home. Safeguarding incidents were not consistently recognised, or action taken to prevent further abuse. The provider failed to deploy sufficient numbers of suitably qualified staff to meet people’s needs and keep them safe. The environment was restrictive and had not been suitably adapted to meet people’s needs. Medicines were not managed safely, and the required MCA processes had not always been followed.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

A relative expressed concern they did not know who to speak with about their relative’s health needs, which they felt were not being managed. They said, “I have tried to talk to the manager, but the manager has changed a lot. I have raised concerns regarding health issues, but nothing has been done.” We also received feedback from people’s relatives about accidents and incidents that had occurred with no satisfactory explanation. Relatives involved in people’s care told us they were informed when incidents or accidents had occurred but were not involved in discussions about risk assessments . Information was not always shared with people and their families following incidents. This was important to make sure everyone understood what had happened and how the service was going to reduce future risks, responding in an open and transparent way and following where necessary the regulation on duty of candour. The provider failed to work in line with the regulation and consistently apply the duty of candour. For example, half of the letters sent to people or their representatives failed to contain sufficient information, including a full account of what had happened, what investigations had been conducted and any action that had been taken to mitigate future risk. However, people and their relatives told us they felt staff knew what they were doing and could meet their needs. One relative said, “They [staff] seem to have the skills to do everything right.”

Staff told us they completed records when incidents and accidents occurred however, we found there was no single log of incidents; these events were recorded in various places, including daily care notes, the handover book and on incident forms. We noted people were sometimes referred to by room number in the handover book and these room numbers did not always relate to the correct person. The provider’s list of people living at the service also had incorrect room numbers for most people. This meant risks to individuals, when staff recorded them using their room numbers, may not have been understood to ensure action would be taken. The provider had failed to create an environment where staff were supported to understand service users’ needs and associated risks and had access to clear and consistent information.

We found the processes in place for learning from safety incidents were not effective. Staff were not always recording incidents, accidents and safeguarding events on the provider’s records system. Where they were recorded, leaders failed to consistently review them. This meant the provider had failed to identify themes and act to prevent a recurrence. For example , there were repeated incidents of a sexual nature between 2 people using the service, which may have resulted in physical or psychological harm to either or both people involved. The provider failed to assess the risk and implement measures or guidance following any of these 5 incidents. This meant people continued to be at risk of significant avoidable harm. When significant incidents or accidents occur, providers are required to follow duty of candour. This means they should review the circumstances, share this with the person or their relative, explain what action they have taken to prevent a recurrence and apologise. We requested the provider’s duty of candour for the 6 months prior to our assessment. We found this had not been applied for some significant incidents that had occurred. Where it had been used, it failed to clearly identify what action that had been taken to reduce further risk. Furthermore, information about incidents and action taken to reduce risks, was not consistently shared with external professionals including CQC and the local authority. This hindered external professionals from having oversight of risk at the service and ensuring appropriate action had been taken in a timely way, which placed people at risk of continued harm. Following our assessment, the provider worked with external professionals to review systems to monitor risks.

Although people’s relatives told us they were involved in decisions about their family member’s care, we found this was not evidenced within people’s care plans and other records. This was important to ensure essential information was shared between services and any risks were known and mitigated.

The management team and staff told us they sought advice and support from external health and social care professionals when needed. However, people’s care records did not have up to date information to evidence this. Staff we spoke with were unable to demonstrate they knew people well and understood their associated risks. This meant people were at risk of harm.

Information about people’s care and support needs was not always accurate and up to date. One external health professional raised concerns staff were unaware of risks associated with people’s health needs. Following our assessment, external social care professionals were working with the provider to make improvements.

There was a process to share hospital passports with different services when needed in order to share essential information about people. However, these failed to contain sufficient information about their essential needs and risks. For example, one person communicated distress in a way that was a risk to themselves and others. There was no information about this risk in their hospital passport, meaning this would be unknown if they moved between services. This meant people were at risk of potential harm because essential information was not being shared.

People were not protected from abuse. The provider, manager and staff had not consistently recognised possible signs of abuse, including unexplained bruising. The provider failed to understand their responsibility to report concerns, or take action to safeguard people. For example, 1 person communicated their distress or needs through regular incidents of physical harm and sexualised behaviour towards others. Another person communicated distress through regular incidents of physical harm and verbal agitation directed at other people. The provider and management team failed to review all incidents and act to prevent a recurrence. This meant people experienced avoidable harm. Additionally, the provider failed to report all safeguarding concerns to the local authority safeguarding team or notify CQC in line with their statutory responsibilities. There was no information in either person’s care plan that clearly identified the risks or provided guidance for staff about how to mitigate them. In addition, there was a restrictive environment within the service where people were prevented from moving freely. Risks to people from being unable to access areas of the home including their bedrooms, bathrooms, the dining room and garden had not been individually assessed People told us they did not consent to these restrictions. Where people may lack capacity to consent, the provider had failed to work in line with the MCA. This meant they had failed to consider what was in a person’s best interest, the least restrictive options available and had failed to respect people’s human rights. One person told us, “There is no life in here [in service], they [staff] should let us out, it’s like a prison in here.” Another said, “I stay in my room, I never get the choice to go downstairs.”

The provider and managers had failed to ensure they and the staff team were effective at identifying when suspected or actual abuse had occurred. This included sharing information with partner agencies, reviewing the circumstances of incidents and ensuring risk assessments were in place or updated following incidents. We found leaders and staff did not recognise abuse or understand what they needed to do about it. For example, one staff member we spoke with did not understand what safeguarding meant and could not remember completing safeguarding training.

We used SOFI to observe people who were unable to verbally communicate with us. We observed staff speaking to people with kindness , while at other times people were ignored by the staff present. We observed poor practice throughout our assessment visits including unsafe manual handling , staff failing to support people who relied on them to eat and drink, and staff failing to respond promptly when people needed support.

The provider had failed to ensure people were safe and action was taken to prevent abuse. Although staff had received training, and the provider had a safeguarding policy in place, staff were unclear about their safeguarding responsibilities. Records viewed showed a large number of safeguarding incidents had occurred, with limited or no action taken, including sharing information with the local authority safeguarding team and CQC. Staff did not escalate concerns when incidents repeatedly occurred. Processes in place were not clear and were not being effectively reviewed to ensure action was taken when needed. Systems to review if people needed deprivation of liberty authorisations, were not robust and failed to effectively monitor applications, ensure any conditions were met and that renewals were applied for when needed. This meant systems in place had failed to safeguard people from repeated abuse.

People were at risk of harm as known risks were not being managed safely. Some people had known risks relating to their eating and drinking needs. For example, one person had a previous history of an eating disorder but no assessment of this risk or discussion with the person and their family was recorded. This meant they were at risk of staff not recognising changes or taking action to prevent harm. Furthermore, people had known risks from diagnosed health conditions such as diabetes, epilepsy and heart conditions. There was insufficient or no information within their care plans about how staff should safely support them to ensure staff would recognise when to take action to prevent harm. People were not supported to take positive risks, and there was a restrictive environment. Relatives expressed, they did not always get a satisfactory explanation of why incidents and accidents had occurred. For example, when a person had left the home without staff knowing. People we spoke with told us staff did not know them or talk with them. One person said, “The staff don’t have much time for me they all hate me.” Another said, “If you want to go out, they [staff] ask a lot of questions”. A third, “I do feel safe in the home, but I do not interact with the staff much.” A relative told us, “My [relative] noticed that the cord on the call bell switch was missing [in their room] and they couldn’t call [staff] for help.”

Leaders did not understand their responsibility to assess and mitigate risks to people. For example, on the first day of our assessment, the manager was unable to demonstrate they understood how to manage risks from people who were communicating distress in a way that posed a risk to themselves and others, and what action to take to ensure these were mitigated. On the second day of our assessment, the manager described how they managed some risks by preventing people from independently accessing communal areas, such as the garden and dining room. We asked why a decision had been made to prevent all people from accessing the garden independently. They were unable to demonstrate risks to each person had been individually assessed. This was important to ensure people were supported to be as independent as possible and could move around their home freely. We found there was a clear lack of understanding from staff and leaders about people’s individual needs and wishes and how to manage risks in a person-centred way. Managers told us nighttime fire drills had not been completed with staff and a staff member confirmed they had not completed any fire drill. They said, “I’ve taken photos of the pictures on the wall [fire instructions] so I can go through the drill, but I’ve not been there when a drill has happened. I have just been told to read the forms on the wall.” We observed there were 2 sets of contradictory fire evacuation instructions for staff on walls in the service. For example, one set of instructions described staff should attempt to put out a fire if trained to do so. The other described that the premises would be evacuated on sounding the alarm. This meant the provider could not be assured staff would understand how to safely evacuate people in the event of an emergency. We discussed this with the provider and shared our concerns with the local fire service.

We used our short observational tool for inspection (SOFI). The results confirmed our observations that there were insufficient staff available to meet people’s needs and manage risks to people. For example, we observed 1 person, who was at high risk of falls and who sometimes communicated distress in a way that was a risk to themselves and others, was not being safely supported. During our observations we saw staff trying to prevent the person leaving a room. Although this was done with kindness, staff did not appear to be following any clear strategy to keep themselves and the person safe. We reviewed this person’s care plan, which did not contain any guidance for staff about how to manage this risk. In addition, we observed staff using unsafe practice when supporting people to move and staff were unable to describe clearly how they would mitigate known risks to people. We observed some people did not have access to call bells near where they were sat in their rooms, which would impact on their ability to summon support when needed.

The systems in place to keep people safe were not effective and people were placed at risk of harm. When incidents or accidents occurred, robust action was not taken to review the circumstances and reduce the risks. Risk assessments did not contain sufficient guidance for staff about how to mitigate potential risks to people. The provider and manager had failed to ensure staff understood how to protect people from harm and that processes were in place to assess and mitigate all risks to people. This meant people were at risk of harm. Following our assessment, the provider worked with external professionals to review care plans and risk assessments.

People and relatives did not raise any specific concerns about the environment being unsafe. However, people and their visitors told us environmental restrictions meant they had to wait for staff to support them to get into their own bedrooms or to access some areas of the home. One visitor told us, “The building is like a rabbit warren. We brought [person’s name] down for lunch, but there was nobody about, we were trapped upstairs for a while. I don’t know the code, nor does [person’s name]. They used to have a [key] card for their room, they now have to wait [to get back in].”

We spoke to staff about why people did not have keys to their own rooms. One staff member said, “It depends on their [person’s] capacity, and they [person] would have to find a member of staff to let them back into their room”. Another said, “[Person’s name] is independent, but I had to go and let him them in their room. They haven’t got a pass[key], they [people] can’t get into their rooms. Everybody has dementia, no one has a key to their bedroom. If they [people] have dementia they won’t remember not getting into their bedroom without staff.” We asked the managers for risk assessments that had been completed for each person to assess the risks from not giving them independent access to their own rooms. We did not receive these. This meant leaders had failed to individually assess any risks to people and in doing so had enabled a culture which had normalised a restrictive environment. We raised this with the provider who took action to review risks to each person and the decision to prevent them independently accessing their own bedroom.

The environment had not been fully adapted to suit the needs of all people. A high number of people living in the service had a diagnosis of dementia. We observed corridors within the home were long and narrow and in some areas of the home carpets and walls were of a similar colour. This could impact on people being able to distinguish between walls and flooring and could increase risks of accidents. Toilets within the service were either locked or were very small with sliding doors onto narrow corridors. This could impact people’s ability to use toilets independently. Furthermore, we observed signage throughout the service was confusing and not dementia friendly. Signs did not clearly identify where toilets and bedrooms were located, did not use pictures or symbols to aid understanding and were not placed where service users could see them easily. For example, toilet doors had small written signs on and there were large arrows on the walls of corridors, some of which were above eye line and pointing in multiple different directions. On the first day of the assessment, we accessed the lift, which had a heavy door to pull open and inner doors which shut quickly behind as people entered. To make the lift move between floors, the button had to be held the whole time the lift was moving. This was a risk to service users with mobility needs or who were living with a cognitive impairment. We asked the provider for risk assessments for all people who had the ability to access to the lift. We received 2 risk assessments for people. However, these were completed after our assessment.

A call bell system was in place so people could press buttons in the room they were in, to alert staff they needed support. We viewed the call bell panel. A staff member explained they had to walk to the panel and check which light was on to know which room to respond to. We identified there was no emergency option for people to use on the call bells in rooms. This was important so if a person was suddenly unwell or fell, they could seek urgent support. The staff member told us a staff member would have to attend the person first, then they press the bell 3 times and then press it and leave it running, so other staff would know it is an emergency call. This was an out of date and ineffective system to ensure people had a prompt response from staff in emergency situations. People had personal emergency evacuation plans (PEEPS). However, these lacked sufficient detail to enable staff to understand how to safely evacuate each person, should they need to. For example, there was no information about the equipment each person would require to safely leave the building. We requested copies of the provider's environmental audits. For example, in relation to electrical safety, equipment and water systems. The provider failed submit copies to us. The provider failed to demonstrate there were processes in place to assess and monitor the environment, and to protect people from avoidable harm. Fire extinguishers and alarms were maintained, and staff tested alarms, doors and emergency lighting. Following our feedback, the provider worked with external professionals to review all systems and processes in place.

During our visits to the service, we found there were insufficient staff available to support people with person centred care. People we spoke with told us staff did not have time to provide care to meet their needs or that supported them to pursue their hobbies and interests. Comments included, “I stay in my room all day unless I go out somewhere with my family, Sometimes the carers come and get me for lunch, but not always, then I have to find my own way to the dining room.” And, “I like to go out for walks, the staff won’t take me out. I have to wait for my [relative] to take me out.” A relative told us, “I leave about 6pm at staff turnover time. There could be no staff in the lounge. It worries me. I was in the lounge and one of the residents [people] had a go at me. There was one staff standing by the door, who reacted very slowly. There were about 20 people in the lounge at that time.” Another said, “On weekends there is not enough staff. They need more staff. When I phone on weekends the phone rings and rings. Sometimes the phone isn’t answered. If you ring after 7pm on weeknights the phone is not answered and staff sound very busy.”

The managers and provider told us they used a dependency tool to determine the number of staff needed to safely support people. The provider told us they felt there were sufficient staff available at night to meet people’s needs. Two staff were in the service between 10pm and 6am, to support 6 people who were cared for in bed and required support to reposition at night. In addition, 5 people posed a risk to themselves or others due to their behaviours. There were insufficient staff available to safely meet people’s needs and support them in an emergency, such as fire. We reviewed incidents and accidents between 22 October 2023 and 7 April 2024. We identified 45 occasions where people required support of 1 or more staff between 10pm and 6am. The provider had failed to ensure there was sufficient staff available at night. Staff told us they felt there were enough staff, although they were busy, they enjoyed working at the home . One staff member said, “It can be busy, it can be hard as we have to support lots of people and then also have to watch [person’s name].” Following our visit, the provider informed us the number of waking staff at night had been increased, however we were not assured robust processes were in place to assess people’s individual needs to determine the number of staff needed to provide safe care.

We visited the service on 3 occasions, including a nighttime visit and observed staff were rushed and did not have time to support people safely. We saw one person who was at risk of choking, was given food that was not in line with their assessed nutritional needs. Staff left the person eating alone, as they had to support other people. This meant the person was at risk of harm. Later during our observation, we had to intervene to prevent the person from falling as no staff were present. Another person was calling out for staff support repeatedly saying, “You [staff] don’t care, what a life this is, you [themself] can’t get a cigarette; no cups of tea." When staff did support the person, we observed they were rushed. The person then called out again for a cup of tea and continued to call out appearing very distressed. It was 13 minutes before staff were able to attend them again. During our daytime observations we found people were left for long periods of time without staff support. For example, some people were cared for in bed and staff did not regularly spend time with them. When they did go in to support them, this was rushed and was not person centred. We used our SOFI to observe people in the main lounge on the second day of our assessment. We saw 1 person attempted to get a staff member’s attention. The staff member told them, “In a rush, be back in a min.” They did not return. This had a negative impact on this person’s experience. Another person was given a mobility aid by staff who placed it in front of them and walked away. There was no communication or offer support, despite the fact this person’s care plan indicated they required the support of staff to mobilise safely. A third person tried to get staff attention. The staff did not respond and walked away. This meant staff were not available or lacked knowledge and training to safely support people.

Systems and processes to assess and monitor staffing levels were ineffective at identifying risks and were not used to underpin safe practice. This had led to people experiencing harm and or distress. Records of staffing rotas showed some staff were working an excessive number of hours each week, with only 1 day off every 2 weeks. This meant people were at risk of harm from being supported by staff who were working excessive hours. The provider failed to ensure all staff were recruited safely and in line with the regulations, for example there were gaps in the employment history and right to work checks for some staff. We shared our concerns with partner agencies. Staff had not received training that equipped them to meet the assessed needs of people living in the home. This was further impacted by insufficient or irregular supervision meetings to monitor and assess their knowledge. A staff member told us, “[Supervision] hasn’t been regular, I can’t remember [last one] really, probably October [2023] time maybe.” Another staff member who had been employed for more than 2 years , had only completed 27 out of the 32 training courses the provider made available to staff. For example, despite holding a senior position they had not completed training in mental capacity awareness, first aid, positive behaviour support and falls prevention. Furthermore, although staff had completed safeguarding training, this was ineffective as leaders and staff had failed to follow the provider’s safeguarding policy or local safeguarding processes. This meant people were at risk of harm from staff who did not have the skills and knowledge needed to support them safely. We took immediate action to discuss our concerns with the provider and partner agencies. As a result, the provider agreed to increase the number of staff available at night to safely meet the needs of people living in the home and review staff training and working times.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were not supported safely with their medicines. Although people and their relatives did not raise any concerns about the medicines, we found people were not receiving their medicines as prescribed.

Staff had not received the necessary training and support to enable them to ensure medicines were administered safely. One staff member confirmed they had not completed all their medicines training but were still administering medicines to people. They said, “I still have to complete the second part of the training. But yes, I do administer medicines.”

We identified some incomplete records in the Controlled Drugs (CD) register, which meant the provider could not be assured these were safely managed. Some administration records for ‘as required’ medicines [PRN] lacked detail of the specific dose administered, whilst others indicated the medicine was not available as they had run out of them. Guidance for staff about when to administer PRN medicines lacked sufficient personalised information and detail. For example, some people were prescribed medicine to reduce agitation and aggression. The PRN guidance for staff to understand how each person may present when they needed these medicines, lacked sufficient detail. This placed people at risk of harm. In addition, some people were being given their medicines covertly, which is when the person is not aware they are receiving medicine, why they need it or how the medicine could impact their health. We found the provider had failed to implement records to ensure the safe administration of covert medicines in line with the MCA. For example, mental capacity assessments, best interest meetings, and a relevant deprivation of liberty safeguard [DoLS] application had not always been made. The provider had failed to ensure the proper and safe management of medicines. Medicines, including controlled drugs which require additional legal controls (CD) and those requiring refrigeration, were stored securely . We asked the provider for evidence of how they monitored systems and processes to manage people’s medicines. We did not receive these. The provider was unable to demonstrate there were processes in place to effectively monitor medicines storage, ordering, recording and administering. We discussed this with the provider, who following our assessment visits worked with external professionals to review systems and processes for the safe management of people’s medicines.