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

There was a poor culture at the service with inconsistent leadership. Staff were not consistently supported to develop their knowledge and understanding of people, to discuss a shared vision or to improve people's lived experiences. Staff did not understand the language used within people’s care plans was sometimes disrespectful and outdated. The way people were being treated indicated a poor culture. The service was not being managed well and governance systems in place were not effective. Audits were ineffective or not being implemented in key areas of the service such as, staff engagement with people, incident and accident reviews, feedback from people, relatives and staff and care planning. Audits that had been completed did not act on issues found in a timely way. Staff supervisions were not regularly taking place. Leaders in the service lacked skills and knowledge and were not empowered to be responsible for all aspects of the service. This lack of oversight has led to poor experiences for people. The provider did not indicate our concerns were understood or that the culture would be improved and embedded.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us they enjoyed working at the service and enjoyed looking after people. However, the failure to appropriately support people with understanding, kindness and compassion as described in the other key questions of this report, shows a poor culture was present at the service. Staff and leaders had not recognised the discrimination of people and the lack of person-centred care with a task focussed, restrictive culture. Staff told us they felt the changes of managers over the previous year had impacted on team morale and consistency. One staff member said, “Having different managers is challenging, each new manager has tried to change things and that unsettles the residents [people].” Staff lacked knowledge and understanding of how to support people and manage risks. One staff member we spoke with was unable to identify unexplained bruising on a person as a reportable safeguarding incident. They told us they didn’t remember doing safeguarding training. Another staff member told us they had not had an interview or an induction when they started working in the service, as they had previous experience. They said, “When I came, I didn’t have an interview, I showed my qualifications and [interviewer] said when do you want to start. That was it. I had no induction.” This meant leaders could not be assured staff had the skills and knowledge, to support people effectively. This had impacted on the development of a poor culture and people’s lived experience.

Leaders had failed to monitor the culture in the service and had failed to identify concerns we found during this assessment. For example, the provider’s ‘dignity, respect and choice’ policy described its purpose as ‘promoting a culture within Autumn House Residential Home that empowers clients [people] to have choice, independence, dignity, respect and control in line with legislation and guidance.’ This had not been followed. Leaders had written people’s care plans using derogatory or outdated language, which further embedded a poor culture. For example, a staff member described a person who had a diagnosis of dementia as, “volatile”. They said, “Even if you talk to [person] nicely, they can be very aggressive.” In addition, we found another person’s care plans referred to them as, ”Controlling, paranoid and obsessive” and institutionalised language such as bed bound, and cot sides was regularly used. This language labels people with negative implications and can impact on the way staff view people who need care and support. The multiple breaches of regulation described within this report are clear indications of a poor culture. People were not being treated with dignity and respect and were not being supported in a person-centred way which identified and achieved positive outcomes. Oversight of the quality of care was ineffective and did not include consideration of people’s lived experience or ensure compliance with the regulations. People and the staff team were not being asked to feedback about the service, which would have helped foster a positive culture and a shared direction. We discussed this with the provider who following our assessment, worked with external social care professionals to review systems and processes and develop a plan to make improvements.

The provider had employed 4 different managers at the service in the year prior to our assessment. This had impacted on the quality of the service provided. Leaders did not demonstrate the skills and experience to be able to drive improvement and ensure there was a compassionate and inclusive service that was safe, caring and responsive to people’s individual needs. Staff understanding of their own role and responsibility to people, had been impacted as result. One staff member said, "You get told what’s been going on during the day, but I don’t know where any risk assessments or care plans are.” However, we did observe some kind and caring interactions between people and staff.

Processes were either not in place or not being followed to ensure action was taken where needed. Leaders had failed to seek people’s views or carry out checks that would enable them to identify where improvements were needed. The management team and staff needed to increase their skills and knowledge to be able to meet people's needs within a safe and inclusive culture.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff working in the service were unaware of their rights and had not been supported to understand the risks to their wellbeing and the safety of the people living in the service. Managers told us they were planning to install an alarm in a house which was occupied by staff recruited internationally, and owned by the provider, so that this could be sounded in the event of an emergency at the home. This meant staff living in this accommodation were always essentially on call. International staff living within the care home building were also described as being available to support in the home at any time in their non-working hours. These conditions were not conducive to supporting staff to have adequate psychological or physical breaks from work and were discriminatory to internationally recruited staff accommodated by the provider. We shared our concerns about these staff with external agencies.

We reviewed 3 staff records including recruitment records, staffing rotas and employment contracts. We found the provider had not ensured all staff were treated fairly and equitably. For example, one staff contract we reviewed had separate terms and conditions for oversees workers which included, requiring them to live in accommodation supplied by the provider and prevented from having their spouse live with them for 2 years. There was a diverse workforce employed at the service. We found the culture in the service was discriminatory towards staff who were employed from oversees on a sponsorship licence. Contracts and conditions for oversees workers differed from those employed from the UK. For example, overseas staff were deemed to be on-call at night because they lived in onsite or in nearby accommodation arranged by the provider. This was not required of other staff. More information about this can be found in the Safe Key Question.

Staff told us they recorded incidents on electronic forms and would report any changes to people’s support and care needs to the management team who would then update care plans. People’s care plans and other records were held on an electronic record system, however, we found staff did not access people’s full care plans via the handheld devices used to record daily tasks, which meant they did not have ready access to information about people. We found incidents, accidents and safeguarding events were not consistently recorded or recognised. We found records of incidents recorded in the handover book, or in daily care notes, which had not been followed up to ensure any action needed was taken. This meant governance systems in place had not ensured staff understood their responsibilities, people’s needs and any risks. One staff member told us, “I find out information [about people] in the handover book or on the handset.” Another said, “I look in the handover book and talk to colleagues. I would know someone is at risk due to my experience. There are only 1 or 2 are at risk of falls.” We found most people living in the service were at risk of falls. Records reviewed demonstrated there was a poor understanding and oversight of risks, systems and processes.

Processes were not in place to effectively manage and monitor the quality of the service. Audits were not being completed in multiple areas of service provision such as people’s care planning, staff training and competency and deprivation of liberty safeguards. The provider had completed action plans which demonstrated action was required in areas such as medicines management. However, no action had been taken to address the shortfalls we found at this assessment. Where the provider had identified action was needed, these had not been completed. For example, the provider had an action plan from October 2023. In February 2024, the action plan was still showing all actions identified had not been completed. We asked for all checks completed by the provider and management team but did not receive these. This meant the provider and management team did not have robust systems in place to monitor care quality and safety and to drive improvement. Following our assessment visits the provider worked with the local authority to review governance systems and consider improvements.

People were not supported by the management team and staff to be able to access their community in line with their individual preferences, reflecting their interests, cultural and spiritual needs. Although external professionals were contacted and visited the service, people were not consistently supported to go out to the shops, to church or to do other activities they were interested in, unless their relatives took them. People and their relatives gave us mixed views about engagement with the management of the service. Between day 1 and 2 of our visits, the manager had changed. Some people told us they did not always know who to speak to and commented the regular change of manager, meant they were not always able to speak up or raise concerns, while others were positive and felt they could speak to management or staff. Relatives’ comments included, “The manager changes often”, “The manager doesn’t always get back to me with information,” and “I can just ring the home and I get put through. They also phone me to keep me updated.” Feedback from people and their relatives was not effectively sought. This meant the impact of poor care to their wellbeing had not been recognised or acted upon.

There was partnership working between the staff team and external professionals. For example, they had regular contact with their local GP surgery and sought advice from the local hospice and mental health professionals. However, we found action to address people’s health and request support from external professionals, was not always sought without delay. When it was sought, advice was not always implemented within people’s care plans and shared with staff to mitigate risks.

We shared the concerns found at this assessment with the local authority, the fire service and other professionals including healthcare staff. We liaised with them and the provider to monitor immediate action taken to reduce risks to people. External professionals we spoke with told us they found their advice had not always been listened to, but they were working to improve partnership working with the management team and staff. This was important to ensure improvements were made and embedded in the culture.

Although, external medical professionals were contacted for people, support was not always sought consistently or in a timely way Information and advice received was not always clearly recorded and shared with staff to reduce known risks to people. We discussed this with the provider who worked with external professionals to build partnerships and implement advice and support following our assessment.

There were signs and risks of a closed culture in the service. Staff, people and their relatives were not routinely asked for, or provided with feedback. Feedback is important because it supports the provider to identify where improvement was needed, apologise when things went wrong and to listen to others’ ideas about the development of the service. The inconsistencies of the management team had impacted on communication with people and staff which meant they failed to monitor and review where improvement was needed and how they could achieve this. Staff were not supported to understand people’s human rights and use best practice to meet people’s needs and provide good person-centred care.

The provider and managers in place during this assessment, failed to demonstrate they had a good understanding of best practice. They had not promoted a culture of learning, improvement and innovation. There were processes in place which were indicative of a controlled environment where people had little choice about how they wanted to live their lives. For example, there was a bath rota, which identified set days people could have a bath, some people felt they could not spend time downstairs, or did not have a choice about where to eat their meals. Although nationally recognised monitoring tools were being used in people’s care plans, these were not completed correctly and action was not always taken to reduce risks, making them ineffective. Processes for reviewing all accidents and incidents had failed and records were inconsistent. Incident and accident reviews had not been documented by managers to ensure people’s care plans were updated and any learning identified. This meant a learning culture was not in place, which left people at continued risk of harm.