Archived: The Orchards

The Orchards is a residential care home providing personal care to up to 21 people aged 65 and over, including people living with dementia. There were 14 people living at the service at the time of inspection.

The care home accommodates people in one adapted building which has been extended over the years and is set over two floors.

People’s experience of using this service and what we found

People at The Orchards did not receive a safe, effective and well led service. We identified concerns relating to people’s safety which included poor oversight of fire safety issues by the provider. A lack of training and guidance for staff on how to support people in the event of a fire, and insufficient staffing levels during the night. This put people at significant risk of harm.

The provider did not ensure staff’s competencies were checked in relation to training received. We have made a recommendation about this.

The provider had no oversight of the safety and quality of the service. Quality assurance systems were not established and operated effectively to ensure compliance with regulations. The premises were not well maintained, and areas were not fit for purpose. This included decoration and furnishings of the premises.

Medicines were not managed safely. Staff did not always have guidance to ensure they administered ‘as and when required’ medicines to people safely. Night staff had not been trained to carry out medicine administration.

Robust systems were not in place to monitor accidents and incidents which placed people at increased risk of harm. Systems did not give clear guidance to staff when to seek medical advice following an accident or incident. We have made a recommendation about this.

Safeguarding concerns had not been reported by staff and management. The registered manager was not clear of their role and responsibility in relation to safeguarding people.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; policies and systems in the service did not support this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Why we inspected

This inspection was prompted by serious concerns we received about the service in relation to care management, staff support and training and poor condition of the premises.

We have found evidence that the provider needs to make improvements. Please see safe, effective and well led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Orchards Care Home on our website at www.cqc.org.uk

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to fire safety, management of medicines, staff training and support, failing to operate effective monitoring systems to improve the quality and safety of the service, poor record keeping, notifications of incidents, and safeguarding people from risk of harm.

Full information about CQC’s regulatory response to more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The Orchards is a residential care home providing personal care to 13 people aged 65 and over, at the time of the inspection. The service can support up to 21 people including people living with dementia.

People’s experience of using this service and what we found

People received safe, person-centred care. Good systems were in place to protect people from abuse. Staff had received safeguarding training and were aware of how to identify and report any signs of abuse.

Staff knew people well and were knowledgeable about when to refer to other health professionals for advice and support. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Communication care plans were in place to support people's communication preferences. People enjoyed the food provided and were supported to make sure they had enough to eat and drink.

Staff cared for people with compassion and kindness and treated them with dignity and respect, their independence was promoted. Care plans were in place and regularly reviewed. This provided staff with relevant information about how to support people in line with their needs and preferences. People were offered opportunities to take part in activities at the home and in the community.

The registered manager and provider were responsive to feedback and committed to continually improve the service. They promoted a very person-centred culture which respected people's diversity. Meetings were

held with people, relatives and staff to exchange information and gather feedback.

The provider had a system for the management of complaints, and people felt able to raise concerns knowing they would be addressed

Since the last inspection, the provider improved risk management and the safety and cleanliness of the environment. The quality of care records in relation to people's safety had improved and recruitment records contained appropriate checks.

For more details, please see the full report which is on the Care Quality Commission website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 27 March 2019) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

People’s experience of using this service: Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe and Well-Led to at least good. The provider had taken action to rectify issues with the electrical safety of the premises following the previous inspection. We made a recommendation about improving quality assurance systems for monitoring the safety of the environment, to ensure action was taken to drive improvement.

During this inspection, we found systems to assess and monitor the safety and quality of the environment had not been improved sufficiently. They had not always been effective and therefore failed to drive improvement. We found some shortfalls with the safety of the premises and quality of the environment, as well as the suitability of the decor for people living with dementia. We made a recommendation about this. There were also shortfalls in systems to monitor the application of the Mental Capacity Act 2005 and staff recruitment.

You can see what action we told the provider to take at the back of the full version of this report.

There was a positive culture within the service and people felt the registered manager was approachable. Staff were knowledgeable about safeguarding and able to raise concerns. Personalised risk assessments were in place for people. Staff supported people to manage their medicines safely. Systems were in place to recruit staff safely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Staff were supported through on-going supervision and they accessed training relevant to people's needs, to ensure these could be met. Staff supported people to access healthcare and maintain a nutritious diet.

We saw people were relaxed in their surroundings and felt comfortable around staff. Staff were kind and promoted people’s independence and treated them with dignity and respect.

People’s care plans were kept up to date and reflected their individual needs and circumstances. People were supported in line with their preferences and were supported to engage in social and leisure activities. An activities coordinator was being recruited to help people access more stimulating and meaningful activities. The provider had a system in place for responding to people's concerns and complaints.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection: At the last inspection, on 27 December 2017, the service was rated Requires Improvement (report published 21 February 2018). The last inspection was a focused inspection, which looked at whether the service was Safe, Effective and Well-Led.

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor this service and inspect in line with our re-inspection schedule or sooner if we receive information of concern.

The Orchards is a care home which accommodates a maximum of 21 people in one adapted building. The home has two communal lounges and one dining room. There were nineteen bedrooms, two of which may be used as shared rooms, and sufficient bathrooms on both floors. A passenger lift services the first floor. There is a car park, and the home is close to local amenities. At the time of our inspection, 18 people were using the service although one person was in hospital.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. The Orchards is registered to provide care and accommodation for older people, some of whom may be living with dementia.

There was a registered manager in post. A registered manager is a person who has registered with the CQC 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.

We found the provider failed to ensure the premises were safe because electrical safety checks were not always completed in a timely manner. We saw previous certificates had expired and one test had not been completed for over two years.

You can see what action we told the provider to take at the back of the full version of the report.

Quality monitoring systems were not always sufficient to identify shortfalls in the service and to drive continuous improvement. We have made a recommendation about the provider ensuring the findings of audit action plans are carried out and to use the results of audits to drive continuous improvements in the service.

There were insufficient plans to guide staff in emergencies, except in the event of a fire. For example, there were no plans for what to do in the event of utility failure or flooding. However, staff were knowledgeable about how to keep people safe and told us the actions they would take in emergency situations. Staff were also clear about their responsibilities to report any abuse or poor care they became aware of. We saw there were systems in place to protect people’s monies deposited within the service. People told us they felt safe and we saw there were risk assessments in place to keep people safe.

At our last inspection, we recommended the provider complete some actions to ensure medication practices were safe. At this inspection, we found these had been completed accurately. People received their medicines as prescribed.

There were few accidents and incidents. These were analysed to identify any patterns or trends, and actions were recorded to reduce reoccurrence.

Staff were recruited safely and staffing levels were sufficient to meet people’s individual needs. People were supported by staff who had a good level of skills and knowledge. Staff received induction, training, supervision and appraisals as required.

The registered manager was aware of their responsibilities for completing notifications and these had been submitted as required to both CQC and safeguarding authorities. They were also aware of their responsibilities regarding the Mental Capacity Act 2005. People had mental capacity assessments in place and when people were assessed as lacking capacity to make their own decisions, people involved in their care were consulted or invited to best interest meetings. Advocates and other professionals were used to ensure people’s views and opinions would be taken into account. Deprivation of Liberty Safeguards (DoLS) applications had been submitted as required.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

We saw people’s nutritional and health needs were met in a timely manner. People were referred to healthcare professionals when required and their advice was followed. People were offered choices of food and drink, their dietary needs and individual preferences were met.

People’s rooms were personalised and the environment had a homely feel. Some steps had been taken to make the environment dementia-friendly, however people, their relatives and staff had all identified the décor could be improved. We have made a recommendation about the provider improving the environment to make it more dementia-friendly.

There were positive comments regarding the registered manager and provider. People were regularly asked for their views and opinions on the service through surveys and meetings, and we found there was an open-door policy where people could access the registered manager at any time. There were service user guides in each person’s room that included relevant information, which people may require.

The service was clean, tidy and free from unpleasant odours. We saw staff wore personal protective equipment (PPE) and cleaning equipment was stored securely. There was a designated member of staff for infection prevention and control.

The service is provided over two floors and offers two communal lounge areas, wet room and toilet facilities, bedrooms, nine of which are en-suite, dining area, kitchen, passenger lift, outside garden space and on-site parking facilities.

This unannounced inspection took place on 13 April 2016. The service was last inspected in September 2014 and at that inspection we found the registered provider was compliant with all the regulations we assessed. At the time of our inspection 19 people were living at the service.

The service has a registered 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.

The service understood how to keep people safe, however we found issues with some of the recording of medicines and the temperature of the room where medicines were stored. Although the registered provider offered assurances these would be addressed we recommended they reviewed their medication policy and followed national guidance to ensure medication practices remained safe.

There were policies and procedures to guide staff in how to safeguard people from the risk of harm and abuse. Staff understood how to report potential abuse and had received training to reinforce their understanding.

The registered manager and staff were following the principles of the Mental Capacity Act 2005 (MCA) and had an understanding of the ensuring people were not being deprived of their liberty (DoLS). The registered manager had submitted a number of applications to ensure people were not unlawfully restricted.

We found staff had been recruited safely and appropriate checks had been completed prior to them working with vulnerable people. Staff had good knowledge and understanding of the needs of the people they were supporting and people told us staff were considerate and kind.

People who used the service were provided with a varied diet and people spoke highly of the food they received. Staff monitored people’s food and fluid intake and made referrals to healthcare professionals when required. People who lived at the service were supported to access health care and attend appointments when needed to ensure their health and wellbeing was maintained.

The service offered a range of in house and external activities and people were encouraged to participate. The registered provider had a complaints procedure which people could use to raise any concerns or issues they had.

People told us the leadership at the service was approachable and supportive and people were encouraged to give their views and opinions on the service. The registered provider promoted an open and transparent organisation and staff were supported through regular supervision, team meetings and year appraisals. The service had developed an effective auditing system to assess and monitor the quality of the service provided.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service and the staff who supported them, and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Improvements had been made in the way staff moved and handled people who used the service.

Risk assessments were completed so staff had guidance in how to support people in ways that minimised the risks.

The manager and staff were aware of The Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS); one DoLS application had been authorised and was in place. Training records showed more of the staff had completed courses in MCA and DoLS since the last inspection.

Is the service effective?

People were able to make choices about aspects of their lives and could take part in some activities inside the service.

People's health and social care needs were assessed with them and there was input from relatives. Specialist needs in relation to diet, falls, mobility and equipment were identified and planned for.

Visitors told us they could see people in private and were made to feel welcome at all times.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people.

People's preferences, likes and dislikes had been recorded and care and support was provided in accordance with people's wishes and choices. Staff demonstrated they knew people's needs and preferences.

Is the service responsive?

We observed staff involved people and offered each one choice in regard to their needs. The staff approach to people who used the service was respectful and friendly.

People had access to a range of health and social care professionals such as GPs, district nurses, dieticians, social workers, dentists, opticians and chiropodists. There was evidence the staff team sought appropriate advice, support and guidance during emergency situations.

Is the service well-led?

Learning from audits took place, there was evidence the manager was continually checking the standard of recording in the care plans and addressing shortfalls when they were found.

Staff were clear about their roles and responsibilities.

What people who used the service, and those that matter to them, said about the care and support they received: -

Comments included, 'It is good here, the staff are smashing and will do anything for you' and 'Lovely staff, they are very pleasant to everyone. I don't want for anything and I'm happy to stay here.' A relative told us, 'Very friendly staff, I am always made to feel welcome.'

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with staff and relatives, and from looking at records. If you want to see the evidence supporting our summary please read the full report.

In this report the name of the registered manager appeared who was not in post and not

managing regulatory activities at this location at the time of the inspection. Their name appeared because they were still on our register at the time. A new manager had been appointed.

Is the service safe?

The manager and staff were aware of The Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS); one DoLS application had been authorised and was in place. Training records showed the majority of staff had completed courses in MCA and DoLS.

The service was clean and tidy and measures were in place to protect people from the risks of cross infection.

The manager set the staff rotas and they took into consideration people's care needs when deciding on the numbers of staff on duty and the skills they required to meet people's needs. The manager was recruiting further staff to ensure staffing levels could be maintained.

Is the service effective?

People were asked for their consent prior to receiving care and support and were asked for their views about activities of living on a daily basis. Mental capacity assessments were carried out and best interest meetings held when people lacked capacity and important decisions were required.

People's health and care needs were not assessed on a regular basis. People who used the service and their relatives had not always been involved in writing plans of care. Care plans were not reviewed and updated appropriately. We saw that some people had behaviours that could be challenging to themselves and other people, but plans were not in place to direct staff on a consistent approach.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to care and welfare of people who used the service.

Visitors told us they were able to see their relatives in private and visiting times were flexible.

Delays in the provision of adequate storage facilities at the service meant that the newly refurbished wet room was not in use. This had the potential to impact on the choice of facilities people could use.

Is the service caring?

People were supported by kind and attentive staff. We observed staff speaking to people in a friendly and professional way. We saw that staff gave people time to respond to questions and encouraged them to make decisions for themselves.

People's preferences, routines, likes and dislikes had been recorded in most cases and care and support was provided in accordance with people's wishes and choices. Staff demonstrated they knew people's needs and preferences.

People who used the service and their relatives were asked for their views in surveys. We saw the majority of the recently returned surveys had positive comments about the care received by people who used the service.

Is the service responsive?

Care records did not always demonstrate there had been changes in people's needs.

People had limited access to social activities. During the visit we observed many people spent time sleeping or sitting in their chairs watching TV.

People had access to a range of health and social care professionals such as: GPs, psychiatrist, dieticians, social workers, dentists, opticians and chiropodists. There was evidence the staff team sought appropriate advice, support and guidance both routinely and during emergency situations. Feedback from health professionals we spoke with during the visit was positive.

Is the service well-led?

There was a quality monitoring system in place that consisted of audits and the seeking of people's views, but we found aspects of the programme had not been maintained in recent months, and therefore not wholly effective in some areas.

Staff had a good understanding of the ethos of the service and told us they enjoyed their work. Staff had policies and procedures to guide their practice and received regular training, supervision and support from management.

What people who used the service, and those that matter to them, said about the care and support they received: -

Comments included: 'I am encouraged to be as independent as I can be, I make my own decisions', 'I usually have my breakfast in bed, because I prefer that' and 'I made the right choice to come here.'

People we spoke with were satisfied with the care they received. One person told us, 'My original doctor won't come out to this home, so the manager is arranging for me to be registered with the same doctor that my friend has here.'

When we asked people how they spent their day, some of the comments were more mixed. They included, 'Not a lot really', 'The staff do not seem very interested', I would like to go out more, we did go out last year', 'I would like to go into the garden or even to the shops', 'I like music, but that doesn't happen, just television all day, and then they go to sleep.' A relative told us, 'The care is good, but there is no stimulation for the service users.'

People who used the service and their relatives were complimentary about the staff team. They commented on the friendliness of the staff. Comments about the staff included, 'The staff are very nice, but they are always rushing, because they are so busy' and 'There seems to be enough of them, they always make time for you. Very nice staff.'

We had not intended to inspect outcome 13 (staffing) but we had concerns there was insufficient staff to meet the needs of people who used the service. People who used the service told us they were often kept waiting when they rang the call bell for assistance and staff confirmed that due to sickness, staffing numbers were low. We found staff were trying their best to cover gaps in staffing levels.

We contacted the provider about this and asked them to produce an action plan straight away regarding how they will address the staffing levels.

People were provided with a choice of suitable and nutritious food and drink. The people we spoke with told us they enjoyed the meals they received and confirmed they were provided with variety and choice.

The premises were clean. The majority of people we spoke with raised no concerns about the general environment but we saw some areas of the home were in need of redecoration. We found the provider did not have a programme in place to address these areas.

We saw appropriate background checks had been carried out on staff before they started to work at the home to make sure they were suitable to work with vulnerable people. One person said, 'The staff are all good. Very even tempered and kind.'

People were made aware of the complaints system. Those we spoke with said they had no complaints but would feel comfortable raising any concerns with the staff.

In this report the name of the registered manager appeared who was not in post and not managing regulatory activities at this location at the time of the inspection. Their name appeared because they were still on our register at the time. A new manager had been appointed.

The four care files we saw included detailed information about the person using the service. We saw evidence that people had access to other healthcare professionals, including GP's, opticians, occupational therapists and district nurses. People's needs were assessed then care and treatment was planned and delivered following their individual care plan. We saw that a number of risk assessments had been completed and were updated on a monthly basis.

Staff told us about the different types of abuse that could occur and what they would do if the thought that it had taken place. One person told us 'I do feel safe here; I can't walk you see and once there was a fire in the laundry, alarms going off and everything but they came and got me, yes, I'm safe.'

Appropriate arrangements were in place for the safe obtaining, handling, storing and disposal of medication. The home had a medication policy in place that outlined how to manage medicines effectively.

We were told that staff were able, from time to time, to obtain further relevant qualifications. Three people we spoke to were undertaking National Vocational Qualifications in Health and Social Care.