Archived: Orchard Manor Limited

Updated 6 January 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This unannounced inspection took place on the 10, 11 and 17 October 2017. The inspection was prompted in part by increased notifications from the provider advising us that some people who lived at the home had sustained a serious injury. The information shared with CQC about the incidents indicated potential concerns about the management of people's care needs. We also brought forward our planned inspection to respond to concerns shared with us by the local authority. This inspection examined those risks.

The inspection team consisted of two inspectors and an expert by experience on the first day, two inspectors on the second day and three inspectors and two specialist advisors on the third day. The specialist advisors were qualified nurses. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of service.

As part of our visit we reviewed information the provider had sent us in response to our last inspection which outlined the action they planned to take to comply with regulations. We asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. This was returned as requested. Providers are required to notify the Care Quality Commission about specific events and incidents that occur including serious injuries to people receiving care and any safeguarding matters. We refer to these as notifications. We reviewed the notifications the provider had sent us and in addition considered feedback provided to us by commissioners of the service and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan what areas we were going to focus on during our inspection visit.

During our inspection visit, we met and spoke with 16 of the people who lived at the home. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk to us. We also spent time observing day to day life and the support people were offered. We spoke with two relatives of people and two visiting health care professional to get their views. In addition we spoke at length with the registered providers, a registered manager and deputy manager who were covering managers, the acting manager, the acting deputy, two senior care assistants, the cook, the acting cook, two care assistants and two care assistants who were working at the home but employed by the Local Authority.

We sampled some records including 11 people’s care plans and 15 people’s medication administration records to see if people were receiving their care as planned. We sampled three staff files and the way the provider had applied their recruitment process. We sampled records about training and quality assurance to see how the provider monitored the quality of the service.

Updated 6 January 2018

This unannounced inspection took place on the 10, 11 and 17 October 2017. The inspection was prompted in part by increased notifications from the provider advising us that some people who lived at the home had sustained a serious injury. The information shared with CQC about the incidents indicated potential concerns about the management of people's care needs. This visit was also brought forward following information of concern being shared with us by the local authority. This inspection examined those risks.

Orchard Manor provides accommodation for up to 34 people who require personal care. At the time of our inspection there were 32 people living at the home.

At our last comprehensive inspection visit in November 2016 we rated the service as 'requires improvement' in all the areas we inspected. We found the provider was in breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as people’s rights were not protected through the effective application of the Mental Capacity Act (2005). The provider was in breach of Regulation 12 regarding safe care and treatment because the management of medicines was not safe. In addition the provider was in breach of Regulation 17 relating to the governance of the service. The provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service and had not maintained accurate complete and contemporaneous records in respect of each service user. After our inspection in November 2016 the registered provider sent us an action plan to show how they would meet the legal requirements of the regulations.

We undertook this unannounced inspection on 10, 11 and 17 October 2017 to check the registered provider had followed their own action plan and to monitor their compliance with the legal requirements of the regulations. During this inspection we found widespread and significant shortfalls in the service; which meant people had experienced harm and or had been exposed to the risk of harm. The required improvements had not been made and the service had deteriorated significantly. We asked the registered provider to take immediate action to ensure the safety of people who had been identified as at high and extreme risk of harm. During day one of our inspection we alerted the Local Authority about the serious safeguarding concerns identified. The local authority attended the service following our escalation and a number of health and social care professionals visited the home to carry out reviews. The Local Authority shared our concerns and provided the home with a team of staff to increase their staffing levels to ensure people were kept safe whilst we considered what further action to take.

There was not a registered manager in place and the home was being managed by an acting manager. 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.

At this inspection in October 2017 we found serious concerns about the safety of the service. People were at risk of and at times had been subjected to unsafe and inadequate care and support. Risks to people relating to the management of people’s physical and mental healthcare needs were not always identified, recorded and known to staff. Staff lacked knowledge of those at risk of choking and measures were not in place to minimise this risk. Skin integrity was poorly managed placing people at risk of injures. Clinical observations which could indicate health concerns were not understood and acted upon. People were not protected from harm due to staff not recognising and reporting safeguarding incidents to the local authority. People were at risk of injury due to unsafe moving and handling practices, poor maintenance of equipment and a lack of suitable equipment.

The home was dirty and smelt offensive. The systems in place to ensure good infection control and prevention and the cleanliness of the environment were not adequate. Infection control practices were reviewed by an infection control nurse and found to be unacceptable. There were insufficient staff numbers available to meet people’s needs safely and in a timely manner. We could not be confident people always received their medicines as prescribed.

People were not supported by sufficient number of care staff who had the training, skills and knowledge to support them effectively. People were not supported in a way that protected them from unlawful restrictions. People did not have their rights upheld and protected due to poor understanding and implementation of the Mental Capacity Act.

People did not have their food and fluids intake managed safely when it had been identified that they were of risk of malnutrition and dehydration. Some people did have contact with healthcare professionals to maintain their health, however, staff had not always identified when healthcare support was required and subsequently throughout our inspection we found people whose healthcare needs had not been met. Sometimes people did not receive the appropriate health interventions when needed.

People did not have their privacy and dignity respected and were not always treated compassionately. We found occasions where people were in a distressed, anxious or unkempt state and the inspection team had to intervene. People were not involved in making decisions and choices about their care and support. Staff did not have time to build meaningful

relationships with people. Some language and daily records used by staff to describe people and their care needs was not dignified. People’s individual cultural and language needs were not met and valued.

People did not receive personalised care which met their needs. The majority of care plans did not reflect people’s current needs, and they were not an accurate or helpful tool for staff providing care. Staff did not know what people’s needs were and how support should be provided. People had not received the opportunity to undertake any range of interesting and stimulating activities that they enjoyed. People did not feel that their concerns and complaints were listened to.

Leadership within the home was woefully inadequate and had failed to ensure positive outcomes for people who lived there. People had been placed at risk of significant harm and many had experienced avoidable harm. The registered provider systems in place failed to ensure people received the care and support they needed and had failed to monitor the quality of the service and ensure people were protected from harm. In addition the registered provider had failed to notify us of events as required by law.

The overall rating for this service was 'Inadequate' and the service was therefore placed into 'Special measures'. Services in special measures are kept under review. Following the inspection we took urgent action to cancel the registration of the provider as people were exposed to ongoing risk of harm and the provider failed to make sufficient and timely improvements. At the time of the publication of this report, our action had been completed and there were no longer any people living at the service.

We found that the provider was not meeting all of the requirements of the law. We found multiple breaches in regulations. You can see what action we told the provider to take at the back of the full version of the report.