CQC report explained · a residential care home
What the CQC found at Autism Care UK (Bedford)
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, June 2022
Rated Requires Improvement; the home had improved from Inadequate, but inspectors found continuing risks with medicines, staffing, personalised care and management.
The inspection was unannounced and took place over five dates in March 2022. Inspectors spoke with people living in the home, relatives, staff and health and social care professionals. They reviewed care records, medicine records, staff files and management records.
There had been some important improvements. The home was no longer rated Inadequate or placed in Special Measures. Inspectors found kind care, safer premises, better infection control, less use of restraint and improved safeguarding. However, staff did not always have the skills or time to support people consistently, particularly when agency staff were used.
The home was still in breach of regulations about safe care and treatment, staffing, personalised care and good governance. Records were sometimes inaccurate, people's communication needs were not always understood, and planned activities and opportunities to build independence did not always happen. The overall rating of Requires Improvement means the service was not consistently meeting the standards people should receive.
Kind and respectful care
People were generally treated with kindness, compassion, privacy and dignity. Staff usually used positive and respectful language.
“They received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to.” from the report
Improved safeguarding
Staff understood how to recognise and report abuse. The home had seen fewer incidents linked to people's distress and was no longer in breach of the safeguarding regulation.
“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report
Safer and cleaner premises
The home had completed maintenance work, improved fire safety and introduced cleaning checks. Inspectors found the premises clean and hygienic.
“The provider had completed all required maintenance in the service.” from the report
Reduced restraint and distress
Staff had become more confident in supporting people during distress. The use of physical restraint and medicines used to manage anxiety had reduced.
“Staff were more confident and more responsive to people's needs and this had resulted in the reduction of periods of distress experienced by people.” from the report
Medicine records and doses
seriousMedicine changes were not always recorded clearly. A recent error meant one person received an overdose for three weeks, and emergency seizure medicine information did not match across records.
“Prescribed medicines were not always recorded accurately.” from the report
Staffing and agency workers
seriousThe home relied regularly on agency staff who did not always know people's needs or communication methods. There were also not always enough suitably skilled staff to support planned activities or community visits.
“This impacted on people as some agency staff were not skilled in how to interact with people, how to safely support them or understand how they preferred to spend their time.” from the report
Communication support
seriousStaff did not always understand or follow people's communication plans. This meant people could become distressed, confused or unable to make their choices understood.
“This meant in some cases they did not describe what signs and gestures the person used or an explanation of what they typically meant.” from the report
Limited goals and activities
needs fixingPeople's longer-term interests and goals were not always recorded with clear steps. Some requested activities, work opportunities and chances to learn skills did not happen.
“While some of these had been identified in care records, no action had been taken by staff to make them happen.” from the report
Weak quality monitoring
seriousManagement checks did not identify all the problems found by inspectors. Records were still incomplete or inaccurate, and the provider's systems did not give enough assurance that concerns would be found and fixed quickly.
“The provider did not identify all of the concerns we found at this inspection.” from the report
- 01What changes have been made to prevent medicine records and emergency medicine instructions from being inaccurate?
- 02How many permanent staff are currently in place, and how do you make sure agency staff understand each person's communication and support needs?
- 03How will you turn each person's interests and goals into regular activities, community opportunities, work placements or independence skills?
- 04How do you check that staff are following each person's communication plan, including the use of Makaton, pictures or other communication aids?
- 05What action has been taken to improve quality monitoring, record accuracy and communication with relatives?
This was an unannounced follow-up inspection assessing the Right support, right care, right culture principles, following up previous breaches and checking infection prevention and control; all five key questions were rated. This explanation was written from the published report of 18 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2021
Autism Care UK (Bedford) was rated Inadequate and placed in special measures after inspectors found serious safety and management failures.
This was an unannounced focused inspection on 26 July and 10 August 2021. Inspectors checked Safe and Well-led because of concerns about risks to people and how the home was managed. They spoke with people, relatives, staff and professionals, and reviewed care, medicine, recruitment and management records.
Inspectors found that some people did not feel safe around other people. Fire safety faults had not been fixed, the home was dirty and poorly maintained, and medicines were not always given or recorded safely. Staff did not always have the skills or clear guidance needed to support people safely.
The home was not person-centred. Records used standard wording, people's choices and goals were not properly reviewed, and there was not enough evidence of consent or approved deprivation of liberty safeguards. Inspectors also found poor oversight, weak quality checks and poor communication from management.
The overall rating fell from Good at the previous inspection, published in February 2019, to Inadequate. The home was placed in special measures. The provider said it had started an action plan and had taken action on fire safety, infection control, cleanliness and maintenance, but inspectors had not yet seen enough evidence of lasting improvement.
Some safety checks
The provider had completed servicing checks for fire and other equipment, and staff carried out regular fire system tests.
“The provider did ensure servicing checks had been completed on fire and other equipment in the service.” from the report
Action after inspection
The provider responded to concerns by starting an action plan and taking steps on fire safety, infection control, cleanliness and maintenance.
“The provider has arranged additional training for staff and put an action plan in place to address other concerns” from the report
Fire safety
seriousFaults with fire doors and other doors being propped open left people at serious risk in a fire. The report says some action was taken afterwards, but the fire service said the status was not fully compliant.
“Faults in relation to fire doors and fire safety identified in a fire service report in August 2020 had still not been addressed at the time of the inspection.” from the report
Medicines
seriousMedicine records had missing signatures and sedative medicine was sometimes used too quickly or too often. One person received it three times in eight hours, creating a serious risk.
“On one occasion, one person was administered this medicine three times in an eight-hour period placing them at serious risk of respiratory difficulties.” from the report
People not protected from harm
seriousA threat to remove access to activities was used to control behaviour. Inspectors said this caused psychological harm, increased anxiety and led to more sedative medicine.
“We found evidence that people had been harmed in the form of psychological abuse, causing unnecessary anxiety and sedation.” from the report
Staff skills and guidance
seriousStaff training was mainly online and their practical competence was not checked. Staff said they had to learn some important tasks on the job and did not understand some care guidance.
“Staff told us they had to 'learn on the job' to meet people's continence care needs and to learn how to safely use a wheelchair.” from the report
Poor management oversight
seriousThe registered manager was often absent, records were not reliably reviewed and quality checks failed to identify serious problems. Relatives also reported poor communication.
“Quality assurance systems had not identified the concerns we found during this inspection and actions that were identified had not been completed.” from the report
Lack of person-centred care
needs fixingGoals and records were standardised rather than based on each person's wishes. There was limited evidence that people, relatives or professionals were involved in decisions and reviews.
“There was no evidence that goals were reviewed, and outcomes were not recorded.” from the report
- 01What fire door and premises repairs have now been completed, and what did the fire service confirm at its follow-up review?
- 02How do you now check that medicines are administered correctly, including as-needed sedative medicines?
- 03What practical training and competency checks have staff completed for communication, anxiety support, continence care and wheelchair use?
- 04How are people's mental capacity, consent and deprivation of liberty arrangements now assessed, recorded and reviewed?
- 05How often is the registered manager present, and how does management now identify and act on safety and quality concerns?
This was a focused inspection of Safe and Well-led only; the other three question areas were not inspected and their previous ratings were used. This explanation was written from the published report of 9 December 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Autism Care UK (Bedford)
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- June 2022Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2021Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- February 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2016Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2015
Registered with the Care Quality Commission on 20 January 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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Most charge £980 to £1,260 a week. 76 can care for a couple. 12 years' experience on average.
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