CQC report explained · a residential care home
What the CQC found at Autumn Leaf House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Requires improvement
- People were protected by safeguarding procedures, safe recruitment, risk assessments and safe medicines management. However, inspectors found that two staff members were not wearing face masks correctly and were not assured PPE was being used safely.
- Effective?
- Good
- This question was not rated in this inspection report.
- Caring?
- Good
- This question was not rated in this inspection report.
- Responsive?
- Good
- Care was personalised and based on detailed, up-to-date information about people's needs, preferences and routines. People were supported with relationships, activities, communication, religion and cultural traditions.
- Well-led?
- Good
- The manager understood their responsibilities, staff described a positive culture, and audits and checks were used to monitor and improve care. People, relatives and staff had opportunities to share their views.
What inspectors found, February 2022
Autumn Leaf House was rated Good overall; inspectors found personalised care and good management, but Safe was Requires Improvement because PPE was not always used correctly.
This was an unannounced inspection on 16 December 2021. Two inspectors spoke with one person, staff and a relative, observed care, and checked care records, medicine records, staff rotas and management audits.
The home was meeting people's needs through personalised care, detailed care records and activities linked to people's interests. People were supported to keep important relationships, follow their religion and cultural traditions, and communicate in ways that suited them.
The main shortfall was infection control. Two staff members were not wearing face masks correctly, and inspectors were not assured that PPE was being used safely. The home had enough staff during the visit, medicines were managed safely, and risks were assessed well.
The overall rating remained Good. Safe fell from Good to Requires Improvement, Responsive fell from Outstanding to Good, and Well-led remained Good. Effective and Caring were not rated in this report.
Personalised care
Staff knew people well and care plans included detailed information about their preferences, routines and communication needs.
“People received responsive care from staff who knew them well.” from the report
Choice and activities
People chose how to spend their time and were supported with activities, family visits, religion and cultural traditions.
“People followed their interests and chose how they spent their time during our visit.” from the report
Safe medicines
Medicines were administered by trained staff, with checks on staff competence and medicine records.
“Medicine administration records confirmed people had received their medicines including 'as required' and controlled drugs with stricter controls as prescribed.” from the report
Good management
The manager and staff promoted a supportive culture, and audits were used to check the quality and safety of care.
“A variety of effective audits and checks were completed to ensure people continued to receive high quality, safe care.” from the report
PPE was not always used correctly
seriousInspectors saw two staff members not wearing face masks as required. One was not wearing a mask and another wore it below their nose on several occasions.
“We were not assured the provider was using PPE effectively and safely.” from the report
Recruitment difficulties
minorThe home had vacant staff posts and was still recruiting. Some agency staff were being used temporarily, although they were described as consistent and familiar with people's needs.
“The recruitment of new staff to fill vacant posts was one of their main priorities.” from the report
- 01What has changed since the inspection to make sure all staff wear PPE correctly?
- 02How many staff posts are currently vacant, and how often are agency staff being used?
- 03How will you make sure care plans and communication information remain up to date?
- 04How can my relative or I raise a complaint, and how will it be handled?
- 05What checks do managers now carry out to identify and correct safety problems?
This was an unannounced focused inspection of Safe, Responsive and Well-led; Effective and Caring were not rated in this report. This explanation was written from the published report of 3 February 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 2019
Autumn Leaf House rated Good; inspectors found safe, personalised care and effective management.
This was an unannounced focused inspection on 13 November 2019. One inspector observed care, spoke with staff and a relative, and reviewed care records, medicine records and management checks. People could not tell inspectors directly about their experiences because of their complex needs.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe recruitment, detailed risk plans, safe medicine systems and a clean environment. Staff understood how to protect people from abuse and respond to emergencies.
The management team was judged to provide effective oversight. Audits and checks were used to manage risks and learn from incidents. The overall rating remained Good, but the other three areas were not inspected during this visit and their previous ratings were carried forward.
Personalised support
Care plans included people's individual goals and guidance for staff. Inspectors found that people were supported in a way that promoted choice, control and independence.
“People's care plans contained detailed information about their individual goals and guidance for staff to support people in achieving them.” from the report
Managing risks
Risks were assessed and staff understood how to reduce them. The home used practical solutions to help people continue activities safely.
“Detailed risk management plans helped staff to manage and reduce risks.” from the report
Staffing and medicines
There were enough staff during the inspection, recruitment checks were completed and staff administering medicines had their competence checked.
“During our visit enough staff were on duty to respond to people's needs in a timely way and maintain their safety.” from the report
Learning from incidents
Incidents were reviewed for triggers and patterns. Staff used debriefings and further training to reduce the chance of problems happening again.
“Each incident was analysed by the provider's positive behaviour support practitioner to identify any triggers and patterns of behaviour.” from the report
Management oversight
The management team worked alongside staff and used audits and monitoring to check quality and risks. People and families were involved in care and their feedback was acted on.
“Quality assurance processes and the results of regular audits demonstrated good governance and effective risk management.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you assess and manage my relative's particular risks, including any distressed behaviour or anxiety?
- 02How many staff will support my relative at different times, and how will you provide one-to-one or two-to-one support when needed?
- 03How do you check that staff remain competent to administer my relative's medicines?
- 04How will my relative be involved in care planning and in choosing activities and social opportunities?
- 05What were the ratings for Effective, Caring and Responsive at the previous comprehensive inspection, and when will these areas next be reviewed?
This was a focused inspection of Safe and Well-led only; the other key question ratings were not inspected and previous ratings were carried forward. This explanation was written from the published report of 5 December 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 Leaf House
5 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- February 2022Goodcurrent ratingstayed GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Goodstayed GoodSafe: GoodWell-led: Good
- August 2019Goodup from Requires improvementSafe: GoodResponsive: OutstandingWell-led: Good
- July 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2016
Registered with the Care Quality Commission on 12 September 2016.
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.
Weigh the report against the rest
Fees, photos and reviews from families
How to read CQC ratings and reports
What to check when you visit
At least 100 live-in carers within about an hour of Solihull
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,250 a week. 78 can care for a couple. 9 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“I have never met a person who is so kind and thinks about others before himself to such an extent as Chris Malagala.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.