CQC report explained · a residential care home
What the CQC found at Autumn House Residential Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, October 2022
Autumn House Residential Home was rated Good overall; inspectors found kind care, but Safe was rated Requires Improvement.
Inspectors visited the home without advance notice on 23 August 2022. Inspection activity continued until 7 September. They spoke with people, family members, staff and outside professionals. They observed care and checked care plans, medicines records, staff files and quality checks.
People and families were mostly positive about the care. Staff were described as kind and caring. Care plans contained useful information, people could access health professionals, and consent and best-interest decisions were generally handled properly.
The main weaknesses were under Safe. Some recruitment checks had not been completed before staff started, medicines records were not always completed correctly, and a safeguarding incident had not been passed to the manager or safeguarding services. Fire safety follow-up and the risk of people becoming socially isolated also needed attention.
The overall rating improved from Requires Improvement to Good since the previous inspection. Effective and Well-led were rated Good. Safe remained Requires Improvement. The report says the home was no longer in breach of regulations that had been breached at the previous inspection.
Kind and caring staff
People and families were mostly positive about staff. Inspectors observed pleasant interactions and positive communication between staff and people.
“Most people and their family members gave us positive feedback about the home and told us staff were kind and caring.” from the report
Improved infection control
The home had arrangements for preventing and managing infections. Staff used protective equipment and cleaning was carried out regularly.
“Appropriate arrangements were in place to control the risk of infection.” from the report
Personalised care planning
Care plans included people's health, social care needs, preferences and choices. Families were usually involved in assessments and planning.
“Care plans contained detailed relevant information about people's health and social care support needs.” from the report
Access to healthcare
People were supported to access doctors, community nurses and other health professionals. Health information was recorded in care plans.
“People and family members told us they were supported to access local healthcare services such as doctors or community nurses.” from the report
Improved management
The overall rating improved from Requires Improvement to Good. The provider had improvement plans and the manager responded to issues identified during the inspection.
“The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.” from the report
Incomplete recruitment checks
needs fixingTwo references were not always received before new staff started. Checks on employment gaps and health declarations were also not consistently completed first.
“We found that two references were not always received prior to new staff commencing employment.” from the report
Safeguarding incident not reported
seriousA safeguarding incident between two people had not been brought to the manager's attention. It had not been reported to safeguarding services, and action to reduce the risk of it happening again had not been taken at the time.
“Although staff had taken appropriate action at the time the manager was unaware of the incident.” from the report
Fire safety and isolation risks
seriousThe manager was not initially aware of actions from an external fire risk assessment. Bedroom doors generally had to stay closed, and the risk of people becoming socially isolated had not been assessed.
“Risk assessments for social isolation had not been completed and we were not assured all reasonable action to mitigate this risk had been taken.” from the report
Night staffing
needs fixingThere were usually two night staff for 40 people. Inspectors were not sure how care would be maintained if one person needed prolonged additional support requiring both staff.
“Although records of care showed people were receiving care throughout the night it was unclear how this would be maintained if a person required prolonged additional care requiring both staff.” from the report
Mixed views about food
minorSome people and families felt meals were small, basic or inconsistent. The manager had already changed catering staff and said meals would continue to be monitored.
“Meals were on the small side and looked basic, however, people were eating and seemed to enjoy it.” from the report
- 01What has been done to make sure references, employment gap checks and health declarations are completed before every new staff member starts?
- 02How do you now check that medicine administration times and signatures are recorded correctly every time?
- 03What action has been completed following the external fire risk assessment, including bedroom doors and asbestos checks?
- 04How many staff are usually on duty overnight, and what happens if one person needs prolonged two-person support?
- 05How have meal sizes, variety and quality been reviewed since inspectors recorded mixed views about the food?
This was a focused inspection that looked at Safe, Effective and Well-led; Caring and Responsive were not inspected and their ratings were not given in this report. This explanation was written from the published report of 1 October 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, March 2021
Rated Requires Improvement; inspectors found risks in infection control, care planning and management systems, although staffing, medicines and kindness were positive.
Inspectors visited on 11 and 22 January and 16 February 2021. This was a focused inspection because of concerns about infection control, staffing, staff skills and people’s medical needs. They looked only at Safe and Well-led.
They found that infection control practices did not always follow guidance during a COVID-19 outbreak. Risk assessments and care plans did not always explain people’s individual needs clearly. Safeguarding concerns were not always handled properly, and training records were not reliable.
There were enough staff, recruitment checks were effective and medicines were managed safely. People and families said staff were kind and caring. However, quality checks had not found or fixed important problems, so both Safe and Well-led were rated Requires Improvement.
The overall rating fell from Good at the previous inspection, published in September 2019. The other three areas were not inspected during this visit, so their earlier ratings were carried forward.
Enough staff
Inspectors found enough staff to meet people’s needs, and call bells were answered quickly. Recruitment checks were also in place.
“There were enough staff available to keep people safe and to meet their needs.” from the report
Medicines
Medicines were stored, ordered and disposed of safely. Plans for medicines given only when needed included instructions for staff.
“People were supported to take their medicines safely.” from the report
Kind care
People and families described staff as kind and caring. Inspectors observed respectful communication.
“During the inspection we observed some interaction between staff and people. Staff listened to people and spoke with them respectfully.” from the report
Clean environment
The home appeared clean and cleaning audits were in place, although inspectors found that infection control procedures were not always followed.
“The service appeared to be clean and the registered manager told us cleaning products used in the home had been reviewed and complied with the standard needed to sanitise COVID.” from the report
Infection control
seriousDuring a COVID-19 outbreak, inspectors saw open clinical waste bags and clean items stored next to dirty items. Staff did not always wear PPE as required.
“We were not assured that the provider was preventing people and staff from catching and spreading infections.” from the report
Incomplete risk plans
seriousCare plans and risk assessments did not always describe people’s specific needs or the equipment and actions staff should use. This included risks such as choking, diabetes, falls and weight loss.
“Care plans and risk assessments did not provide a clear plan as to what people's needs were or how these should be met.” from the report
Safeguarding response
seriousManagement did not always respond properly or promptly when safeguarding concerns were raised. Staff were not all clear about how to report concerns involving management.
“The management team did not always respond in a timely manner, in line with local safeguarding procedures when safeguarding concerns were reported to them.” from the report
Training records
needs fixingTraining records were disorganised and did not show reliably that staff had completed essential training on time. The provider supplied further information after the inspection.
“At the time if the inspection we were not able to be assured that staff had received adequate training in a timely way to equip them to do their roles, safely and effectively.” from the report
Weak quality checks
seriousAudits had not identified the problems with infection control, training, care planning and risk assessments. Accident records also did not clearly show timely investigation or learning.
“The provider's quality assurance system comprised of a range of audits; however, the audits had not picked up the concerns we identified in relation to infection control issues, training and care planning and risk assessments.” from the report
Missed notifications
seriousThe home had not told CQC about four possible serious injuries and all safeguarding concerns within the required timescale.
“The failure to notify CQC of significant events without delay was a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009.” from the report
- 01What changes have you made to infection control, including clinical waste, laundry and PPE, since the inspection?
- 02How do you now make sure each person has a clear, up-to-date risk assessment and care plan for needs such as choking, diabetes, falls, continence and nutrition?
- 03How are safeguarding concerns reported to the local authority, CQC or police when necessary, including concerns about management?
- 04How do you check that every staff member has completed essential training on time?
- 05What action has been taken in response to the CQC action plan, and what evidence can you show of improvement?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 31 March 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 Autumn House Residential Home
5 rated inspections over 7 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Autumn House Residential Home →
- March 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Autumn House Residential Home →
- September 2019Goodup from Requires improvementSafe: GoodEffective: Requires improvementWell-led: Good
- September 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2015GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- August 2011
Registered with the Care Quality Commission on 4 August 2011.
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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