CQC report explained · a nursing home
What the CQC found at Autumn House Nursing Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found risk assessments and care plans were in place and reviewed. They also found enough suitably skilled staff, safe recruitment, safe medicines systems and effective infection control.
- Effective?
- Good
- Staff understood people's health needs, training was kept up to date and consent was sought. People had support with food, drinks, personal care and access to health professionals.
- Caring?
- Good
- People were supported by kind and respectful staff. They were involved in decisions, treated with dignity and encouraged to remain independent where possible.
- Responsive?
- Good
- Care plans included people's life history, preferences and communication needs. People and relatives understood how to complain, and inspectors saw support for activities, relationships and end-of-life wishes.
- Well-led?
- Good
- The home had systems to monitor care, medicines, call bells and records. People, relatives and staff were involved in improvements, and the manager promoted learning from incidents and feedback.
What inspectors found, February 2023
Rated Good; inspectors found safe, kind and personalised care, with improvements since the previous inspection.
This was an unannounced inspection on 19 January 2023. One inspector and an Expert by Experience spoke with people, relatives and staff, observed care, and checked care, medicine, recruitment and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough trained staff, safe medicines systems, good infection control and suitable risk assessments.
People said staff were kind, respectful and understood their choices. Care plans recorded people's needs and preferences, people were supported to see health professionals, and complaints were handled through the home's procedure.
The previous inspection, published on 24 April 2019, rated the home Requires Improvement. Inspectors said improvements had been made in every area that previously needed work. The home remained Good for Caring.
Safe staffing and risk support
Inspectors found enough suitably skilled staff and saw that risks were assessed, with guidance for staff on keeping people safe.
“There were enough staff to follow these plans and minimise risks to people's safety.” from the report
Safe medicines
Medicines were stored safely and records showed that medicines, including creams and lotions, had been administered and recorded.
“There was guidance in place to ensure staff understood how to administer people's medicines including when medicines were prescribed on an as required basis.” from the report
Kind and respectful care
People described staff as kind and caring. Inspectors saw staff offering reassurance, respecting privacy and helping people make their own choices.
“People received their care and support from staff who they described as 'kind and caring'.” from the report
Personalised support
Care plans included people's life histories, preferences and communication needs. Staff used this information when providing support.
“People's care plans included information about people's life history and their preferences and were reviewed regularly.” from the report
Improved leadership
Inspectors found better monitoring of care and more accurate electronic records than at the previous inspection. The home also had systems for learning from incidents and feedback.
“The provider had an electronic system in place which ensured people's needs were met and staff recorded accurately the care people had received.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you keep staff training and competency checks up to date for the needs my relative has?
- 02How do you check that medicines records, including creams and as-required medicines, remain accurate?
- 03What refurbishment work is still planned, and how will it affect residents?
- 04How will my relative's communication needs and personal preferences be recorded and shared with staff?
- 05How will you record and follow my relative's wishes about end-of-life care?
This was an unannounced inspection of the home covering all five key questions, including infection prevention and control; the previous inspection was published on 24 April 2019. This explanation was written from the published report of 14 February 2023 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, April 2019
Rated Requires Improvement; inspectors found kind, respectful care, but medicines, records, staff training and legal safeguards were not always reliable.
This was an unannounced inspection on 19 March 2019. Inspectors spoke with people, relatives, staff, the manager and provider. They observed care, checked seven care records, reviewed medicines for ten people and examined staff and management records.
The home was caring, and people were treated with patience, dignity and respect. Staffing levels, recruitment, cleanliness, food and links with health professionals were also positive. However, medicines guidance was not always complete, care records were sometimes out of date, and staff training had important gaps.
People's legal rights were not always protected because staff did not understand the Mental Capacity Act and Deprivation of Liberty Safeguards well enough. Care was not always personalised or responsive, including for someone receiving end of life care. The overall rating and all questions except Caring were Requires Improvement.
Kind and respectful staff
People described staff as caring and helpful. Inspectors saw staff showing patience and supporting people's dignity, privacy and independence.
“People were supported by caring and compassionate staff who supported people with patience.” from the report
People felt safe
People and relatives said they felt safe. Staff understood how to recognise and report suspected abuse.
“People were safeguarded from the risk of abuse because staff understood how to recognise and report suspected abuse.” from the report
Staffing and recruitment
Inspectors found enough staff available to meet people's needs. The provider followed safe recruitment practices.
“We saw there were enough staff available who were deployed effectively to ensure people received support when they needed it.” from the report
Food and healthcare
People enjoyed the food and were offered choices. Staff worked with health professionals and followed their guidance.
“People told us they enjoyed the food and had choices at each mealtime.” from the report
Feedback was used
The home gathered feedback through questionnaires and meetings. People said these meetings gave them a chance to raise issues, and the information was used to make improvements.
“The information gained was used to make improvements to the service people received.” from the report
Medicines guidance
seriousInstructions for some as-required medicines and topical creams did not give staff enough detail. The manager had identified this, but the improvements were not fully in place.
“There was not always enough guidance for staff to follow when people needed 'as required' medicines.” from the report
Legal rights and consent
seriousStaff could not explain the Mental Capacity Act or Deprivation of Liberty Safeguards. Records also contained conflicting information about people's capacity, creating a risk that care would not follow the law.
“One person had an authorisation in place to deprive them of their liberty, however staff were unaware of this.” from the report
Staff training
needs fixingSome staff had significant gaps in training, including the Mental Capacity Act and health and safety. Staff said they were waiting for further training.
“We identified significant gaps in the training records of some staff, for example, Mental Capacity Act and Health and Safety.” from the report
Out-of-date care records
needs fixingSome records did not accurately reflect people's current needs and preferences. Staff were not always aware of the choices people had made.
“Records contained conflicting information and were not always up to date and reflective of people's current needs.” from the report
End of life planning
needs fixingThe care record for one person receiving end of life care did not contain enough information about their wishes. This could mean the person's preferred care was not followed.
“It did not contain sufficient information about their wishes to ensure they received the care and support they wanted at this time.” from the report
- 01What has been completed since the inspection to make medicines guidance complete on both floors?
- 02How do you check that staff understand the Mental Capacity Act and any Deprivation of Liberty Safeguards authorisations?
- 03How often are care records checked and updated to reflect each person's current needs, choices and preferences?
- 04What training gaps remain, particularly for the Mental Capacity Act and health and safety?
- 05How will you record and follow each person's wishes about end of life care?
This was an unannounced first ratings inspection covering the home, the care provided and all five CQC questions; there were no previous ratings to carry over. This explanation was written from the published report of 25 April 2019 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 Autumn House Nursing Home
2 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2017
Registered with the Care Quality Commission on 25 October 2017.
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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