The inspection took place on 9 and 11 July 2018 and was unannounced.

Autumn House is a 'care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Autumn House is registered to provide accommodation for up to 44 people, including people living with dementia care needs. At the time of our inspection, there were 35 people living at the service. The service was arranged over three floors connected by staircases and one lift. Accommodation was arranged over the ground and second floors, and the third floor was used as an area for staff and management only. All bedrooms had en-suite facilities and there were three communal bathrooms positioned on the ground and first floors. There were three lounges, two dining rooms and a garden area that people could easily access.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The last inspection of this service was in December 2015, when the service was rated Good overall. At this inspection, we found the service was not meeting legal requirements and was rated Requires Improvement.

There were quality assurance systems in place based on a range of audits. However, we found these were not always effective and had not identified the concerns raised during the inspection.

The service used a computerised care system for people’s care plans and associated records, however this was not always clear and did not provide the registered manager with a robust oversight of how people’s needs were being managed.

People’s care plans contained individual information, however some areas did not always reflect people’s needs consistently. Risks to people were not always managed effectively to ensure they were minimised.

Although staff told us they felt supported in their role, we identified that training was not always up to date.

Staff who administered medicines had received training and had their competency to administer medicines assessed to ensure their practice was safe. However, we identified medicines were not always stored safely.

The provider and registered manager had an understanding around their responsibilities of protecting people’s rights in line with the Mental Capacity Act 2005; however, this was not always recorded and best interest decisions had not been completed appropriately. Action had not always been taken to ensure that decisions were legally made on people’s behalf.

People and their families felt the home was safe and staff were aware of their responsibilities to safeguard people from abuse.

There were enough staff to meet people’s needs in a timely way. Appropriate recruitment procedures were in place and pre-employment checks were completed before staff started working with people.

People’s dietary needs were met and they received appropriate support to eat and drink enough. Adaptations and improvements had been made to the home to make it supportive of the people living there.

People were supported to access healthcare services when needed. Staff made information available to other healthcare providers to help ensure continuity of care and supported communication between people and health professionals.

People were cared for with kindness and compassion. Staff knew people well and built positive relationships with them. They were skilled at engaging with people to effectively meet people’s communication needs.

Staff protected people’s privacy and dignity. They encouraged people to remain as independent as possible and involved them in planning the care

During our previous inspection on 17 October 2013 we identified concerns in relation to staffing and set a compliance action. During this inspection, we considered all the evidence we had gathered under the outcomes we inspected. We spoke with eight people who use the service, two family members of people who were unable to communicate with due to their mental frailty and six members of staff, including the registered manager. We also looked at four care plans and records relating to the management of the service.

We looked at the areas of respecting and involving people who used the service, care and welfare, safeguarding vulnerable adults, staffing and quality assurance. We used the information to answer the five questions we always ask;

• Is the service safe?

• Is the service effective?

• Is the service caring?

• Is the service responsive?

• Is the service well-led?

This is a summary of what we found:

Is the service safe?

The service was safe because the provider ensured there were sufficient staff with the right skills to meet people’s needs, and risks were managed effectively. Equipment required to manage risks was readily available, such as walking aids and pressure relieving cushions.

People who used the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Staff had received appropriate training in safeguarding vulnerable adults and we found the manager had responded appropriately to an incident of potential abuse.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service had policies and procedures in place in relation to MCA and DoLS. One person was subject of a DoLS authorisation and we saw they were receiving appropriate monitoring and support.

Is the service effective?

The service was effective because people were cared for by staff who were knowledgeable about their needs and had the skills to provide appropriate care and support. People and their families praised the standard of care and confirmed their (or their relative’s) needs were met consistently. One person said, “I can’t fault the place, they’ll do anything for you.” A family member told us “Everything is wonderful; you can’t fault them; there’s nothing they could improve.” Care records showed people had access to appropriate medical care, including GPs, dentists and chiropodists. People’s needs were clearly known and met.

The home was undergoing a process of redecoration, having secured funding from a national charity. Although this had caused some disruption to the home, the manager told us they felt it had been managed well and was “going to be worth it”. We viewed areas of the home where work had been completed and saw these met good practice guidance for environments where people were living with dementia.

Is the service caring?

We found the atmosphere at the home felt friendly and people were supported in a kind and caring way. One person said, “They treat me very well.” A family member told us “The staff really care, they’re fantastic.” A staff member commented that “Everyone belongs to someone and needs to be loved.”

We observed care and support being provided in communal areas. We saw staff interacting positively with people, using people’s preferred names and speaking with them in a calm and respectful way. They took time to sit and engage with people and understand their needs.

Is the service responsive?

The service was responsive to people’s changing needs. We saw assessments were carried out before people moved to the home and their care plans were updated monthly. A visiting community health care professional said of the staff “They’re very positive and very accommodating. We work well with them and they alert us early to any concerns.”

We found people had been consulted about the redecoration programme and had been involved in designing themed areas in the home. An accessible garden had been created which also served as a smoking area and we saw this being well used by people and their families. Assessments had been completed of people’s ability to navigate their way around the home. Key fobs and keypad codes had been given to people who were capable of accessing certain areas of the home freely and safely, which helped promote their independence.

Is the service well-led?

There was a clear management structure in place; the home benefited from an experienced, stable management team and experienced low staff turnover. The manager actively monitored the quality of service delivered through a range of audits. We saw these were used to identify and make improvements where needed.

The home operated a “key worker” system, where people were allocated a staff member to act as a point of contact for the person and their relatives. Records showed key workers spent time with people at least once a month to check they were happy with the way the home was operating.

The provider took account of complaints and comments to improve the service. Records showed complaints were recorded, investigated and resolved in a timely way. Systems were in place to ensure lessons were learned from incidents.

We spoke with three of the 39 people who were living at the home. They all said they were very happy with the way they were cared for. One person told us “the staff are lovely and I’m happy here”. Another said “the staff take us out along the sea front when it’s nice, you won’t find any problems here”. Although we were not able to have a conversation with some other people we met them and observed some of their care and staff interactions in communal areas. We also spoke with ten visitors. They were positive about the care their relatives were receiving. One said “I have no worries; whatever time I visit everything is good”. “Another added how “impressed they were with the staff” who “were always friendly even though sometimes the residents can be horrible to them”.

We spoke with three staff on who were on duty and telephoned night staff in the evening. Staff were aware of how people should be supported, individual likes and dislikes and the help they required. Most staff felt they had sufficient time to meet people’s needs and had completed relevant training. Appropriate recruitment and induction procedures were in place.

We observed staff were courteous and respectful of people's views and choices were offered. The care we observed corresponded with care plans and risk assessments viewed. The home was clean and there were systems in place to manage infection control risks. There were also systems in place to monitor the quality of the service provided.

However, we found, on occasions, people were woken by night staff and assisted with personal care and dressed early in the morning. We also observed there were insufficient staff to support people at lunch time and people did not receive their meal hot or in a pleasant social setting.

We met all the people who live at the home however we were unable to gain a lot of information from them due to their mental frailty. We therefore spent time in the home’s communal lounges and dining rooms observing people and the way they were cared for.

We also spoke with visitors to obtain their views about the service provided.

We spoke with other professionals involved in the care of people. They stated that they had no concerns about how people’s health and care needs were met. Professionals were complimentary about the way the service met people’s physical and cognitive needs.

Everyone we spoke with confirmed that people’s privacy and dignity were maintained at all times and that people were able to make day to day decisions such as what time they got up and how and where they spent their time.

We observed that people were enjoying their lunch time meal. Those able to respond told us meals were good and that alternatives were provided. Relatives echoed these views about meals and told us about special meals that had been provided for example a party to celebrate a family occasion.

Visitors and people said that they had no concerns about how their personal care needs were met. We were told that if people were unwell then staff would contact a doctor for them. We were also told that staff were available when people needed them and knew what care they required.

Visitors said that they felt staff were available whenever their relatives needed assistance. They also said that staff were very pleasant and had the necessary time to meet people’s needs. Visitors said they were always impressed by the way staff supported people in a relaxed and friendly way. They felt this contributed to the happy family atmosphere at the home.

People and relatives said that if they had any concerns or complaints they would raise these with the manager. Nobody had any concerns when we spoke with them.

This inspection took place on 19 and 22 October 2015 and was unannounced. The home provides accommodation for up to 44 people, including people living with dementia care needs. There were 41 people living at the home when we visited.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People told us they felt safe at Autumn House. Staff had received training in safeguarding adults and knew how to identify, prevent and report abuse. When people were found to have unexplained bruising, the cause was investigated in all but one case. The systems used to manage medicines were safe, although the application of some creams was not always recorded accurately.

People received enough to eat and drink. However, practices used to support people did not always follow accepted best practice and a plan to protect one person from the risk of malnutrition had not been followed.

Staff followed legislation designed to protect people rights and freedom, although they had not complete the process fully for one person due to a misunderstanding between them and a health professional.

Risks to people’s health were assessed, reviewed and managed effectively. When people fell, action was taken to reduce the likelihood of further falls. There were enough staff to meet people’s needs and keep them safe. The process used to recruit staff ensured that only suitable people were employed.

People received effective care from staff who were suitably trained and supported in their role. Staff had good working relationships with external professionals, which allowed them to develop effective interventions to support people.

Best practice guidance had been followed in the design of the home. Good lighting levels, bright colour schemes and pictures placed at appropriate heights were used to create a pleasant environment suitable for people living with dementia.

People were cared for with kindness and compassion and we observed positive interactions between people and staff. Staff used their knowledge of people’s lives and backgrounds to build meaningful relationships. People were encouraged to be as independent as possible and their privacy and dignity were protected. People were involved in assessing, planning and agreeing the care and support they received.

People received personalised care from staff who understood and met their needs well. A new, computerised, system of care planning was being introduced, which would help make sure that people receive consistent and effective care and support. People were encouraged to take part in activities and had formed a number of social groups.

Staff understood the needs of people living with dementia who had difficulty expressing themselves verbally. They picked up on changes in people’s mood or behaviour and provided reassurance when people became anxious.

People felt the home was well-run. There was a close working relationship between management and staff. Staff were happy, motivated and worked well as a team. They understood their roles and were organised well.

There was an open and transparent culture, good working relationships with external professionals and appropriate links with the community. The provider sought and acted on feedback from people. Audits were conducted to assess, monitor and improve the quality of service. A development plan was in place to improve the home further.