Archived: Orchard Lodge

Orchard Lodge is a residential care service that is registered to provide accommodation, nursing and personal care for people with learning disabilities or autistic spectrum disorder, physical disabilities, and younger adults.

The service was registered for the support of up to 33 people. At the time of the inspection 13 people were using the service. The service consisted of two separate bungalows, Orchard and Bouldings Lodge, and was in private grounds in the countryside near a large town.

Orchard Lodge is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

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

There was unsafe assessment, monitoring and management of risk for people with support needs regarding behaviours that may challenge, sexuality, constipation, aspiration, respiration, skin integrity, mobility and posture. Staff did not always have the required competencies or knowledge to meet people’s individual needs safely. This had meant people had been exposed to risk of harm and had been harmed.

Staff practice, and reporting systems to safeguard people from abuse, were not always effective to ensure people were safe from harm. Lessons were not always learnt, and actions not taken to investigate safety incidents and prevent them re-occurring. This had exposed people to actual and high risk of harm over prolonged periods.

People’s care records were not always up to date or accurate. Service management and the provider’s wider quality assurance and governance systems had not always ensured actions were taken to address any issues and risks in a timely manner. The provider had failed to act upon known areas of concern, non-compliance and risk to improve the quality of care for people at Orchard Lodge. This had exposed people to on-going poor care and risk of avoidable harm.

Medicines were not always managed safely. People had not always received their medicines as intended when required. PRN protocols were not always accurate according to what was prescribed or gave clear instructions for staff to manage people’s medicines. This increased the risk people’s medicines may not be given safely or effectively.

Feedback from partnership agencies indicated staff were taking steps to improve their engagement and initiative to refer people for outside help, although work was required to make sure all recommendations were then acted on. We found examples where ineffective partnership working had impacted on people's safety.

Staff practice regarding risks associated with service users deteriorating health and hydration had improved since the previous inspection, although more work was needed to make sure staff practice was consistent in these areas.

Arrangements to make sure the premises were kept clean and hygienic on a day to day basis were not always effective. There were offensive odours caused by urine in one person’s room and significant unidentified staining on walls in other people’s bedrooms. This increased the risk of infection.

The provider had taken action to manage infections during the Covid-19 pandemic. Additional infection prevention and control measures in line with Department of Health and Social care guidelines had been put in place to ensure people’s safety.

Staff always wore personal preventative equipment (PPE) when supporting people. The provider had ensured there were adequate stocks and supplies of PPE available. Staff had alerted appropriate external agencies in when they had displayed signs and symptoms of Covid-19. This had helped prevent infection and maintain people’s health and well-being

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

Right support:

The model of care and setting did not maximise people’s choice, control and

independence.

The model of care delivery at the service focused on people’s medical, rather than their social support needs.

The location of the service was geographically isolated, and people relied exclusively on staff to be able to leave. Opportunities for people to access the local community were limited.

Staff wore uniforms and name badges to say they were care staff when supporting people inside and outside the service.

The size of the service was larger than current best practice guidance. There were identifying signs on the road before the service’s private drive, the service grounds and on the exterior of each bungalow to indicate it was a care home.

Right care:

Care was not always person-centred or promoted people’s dignity, privacy and human

Rights.

People’s privacy and dignity had not always been considered, respected or understood by staff.

Staff did not always respond in a timely or compassionate or appropriate way when people experienced pain or distress.

Right culture:

The provider told us they planned to make changes to ensure they could provide compassionate and inclusive support that promoted people’s choice and independence.

However, significant work was still needed to change the existing culture, ethos, attitude and practice of staff at Orchard Lodge in order to achieve this vision.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 21 February 2020). The service remains rated inadequate. The service has been rated inadequate for the last four consecutive inspections.

At the last inspection we found multiple breaches of regulations. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We carried out an unannounced comprehensive inspection of this service on 20 and 21 November 2019. Breaches of legal requirements were found. We undertook this focused inspection to confirm the provider now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Orchard Lodge 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 four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regulations 12, 13, 17, 18 in relation to: safe care and treatment, safeguarding people from abuse, good governance and staffing.

We have also identified a breach of Care Quality Commission (Registration) Regulations 2009 in relation to failing to notify CQC of incidents regarding abuse or allegations of abuse in relation to service users.

We took enforcement action to issue a Notice of Decision to vary a condition of the provider's registration and remove this location. Orchard Lodge is now de-registered and the provider is no longer able to provide regulated activities at or from this location.

Orchard Lodge is a residential care service that is registered to provide accommodation, nursing and personal care for younger adults with learning disabilities or autistic spectrum disorder and physical disabilities.

Orchard Lodge is owned and operated by the provider Sussex Healthcare. Services operated by Sussex Healthcare have been subject to a period of increased monitoring and support by local authority commissioners. Due to concerns raised about the provider, Sussex Healthcare is currently subject to a police investigation. The investigation is on-going, and no conclusions have yet been reached.

Orchard Lodge had been built and registered before the Care Quality Commission (CQC) policy for providers of learning disability or autism services ‘Registering the Right Support’ (RRS) had been published. The guidance and values included in the RRS policy advocate choice and promotion of independence and inclusion, so people using learning disability or autism services can live as ordinary a life as any other citizen.

The service did not consistently apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons; People did not always receive personalised care. People did not always plan, review or develop their individual support needs and wishes. People did not always have support with meaningful activities. People’s communication needs were not always met. Staff did not always support people with dignity or to be as independent as they were able to be.

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

The service was registered for the support of up to 33 people. At the time of the inspection 14 people in total were using the service. This is larger than current best practice guidance.

The service consisted of two separate bungalows, Orchard and Boldings Lodge, and was in private grounds in the countryside near a large town. Both bungalows were bigger than most domestic style properties. There were identifying signs on the road before the service’s private drive, the service grounds and on the exterior of each bungalow to indicate it was a care home. Staff wore uniforms and name badges to say they were care staff when coming and going with people.

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

Risks to people were not always adequately assessed, monitored and managed, causing or exposing people to risk of harm. People were not protected from infection. Staff practice and reporting systems to safeguard people from abuse were not always effective. Lessons were not always learnt, and actions taken to investigate safety incidents and prevent them re-occurring.

Best practice guidance was not always considered when assessing people’s needs, or what people wanted from their support. Staff did not always have the right skills, knowledge or experience to deliver effective care to people. People’s complex eating and drinking needs were not always met effectively or safely. People’s day to day health and well-being needs were not always met effectively.

People were not always treated with respect, kindness or compassion, or supported to express their views and be involved in their care. Care plans were not always updated when people’s needs changed to ensure staff knew how to support people. People’s care was not always planned in a manner that accounted for people’s personal history, individual likes and dislikes, social interests and how this informed their support needs and choices.

People did not always have support to follow their interests and take part in appropriate social activities or access the community. The service was not always meeting the communication needs of people with a disability or sensory loss.

Service management and the provider’s wider quality assurance and governance systems had not always ensured actions were taken to address any issues and risks in a timely manner. The provider had not ensured that staff at all levels understood their responsibilities and managed staff accountability effectively. The provider had not always shared information openly and honestly. Staff had not always displayed values consistent with the provider’s vision of delivering high quality, person-centred care.

Medicines were being managed safely. There were safe recruitment practices. The premises had been designed to accommodate people’s needs and was decorated in a personalised manner. We found some people’s cultural support needs were met in a caring and responsive manner. One person told us they liked living at the service and the staff were kind. Several relatives told us they thought staff were caring and they were very happy with the care their family members were receiving.

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

Rating at last inspection

We last inspected this service in April and May 2019. The service was rated Inadequate (Published 4 July 2019). There were multiple breaches of regulations and the service remained placed in special measures.

Following this inspection, the service remained rated Inadequate, with multiple breaches of regulations and placed in special measures.

The service has now been rated Inadequate for three consecutive inspections. There have been multiple breaches of regulations identified at the previous six consecutive inspections.

Orchard Lodge has been placed in special measures since September 2017. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. Services in special measures will be kept under review and, if needed could be escalated to urgent enforcement action.

There had been no registered manager at Orchard Lodge since May 2018. The provider had failed comply with Section 33 of the Health and Social Care Act which stipulates that it is a condition of their registration to have a registered manager at the location.

Why we inspected

This was a planned comprehensive inspection based on the previous rating.

This inspection looked to see if the provider had acted to make significant improvements to achieve compliance with regulations.

Enforcement

At this inspection, we have identified four continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regulations 9, 10, 12, and 17. We identified breaches of regulation 11, 13 and 18 in relation to: person centred care, dignity and respect, safe care and treatment, consent, safeguarding people from abuse, good governance and staffing. We also identified a breach of CQC (Registration) Regulations 2009 regulation 18, regarding failing to notify CQC of incidents as required.

Following the inspection in April and May 2019, due to repeated concerns about people’s safety we imposed conditions on the provider’s registration. These conditions relate exclusively to this service. The conditions mean that the provider must ensure a registered nurse who is independent from the service carries out audits and sends to the CQC monthly information about choking risks, clinical decisions and medicines. We used this information to monitor and inspect this service and to understand the actions the provider has taken to improve.

We wrote to the provider on 9 June 2020 to inform them of our serious and on-going concerns prior and since the November 2019 inspection regarding unsafe care and treatment, failing to protect people from abuse and avoidable harm, governance and staffing at Orchard Lodge. We informed the provider in light of the COVID-19 pandemic and the additional pressures the provider and people using the service were currently facing, we have decided against undertaking further enforcement activity.

We have asked the provider to instead focus on driving improvement in the areas identified above. It is important to state that under normal circumstances our findings would have resulted in enforcement activity being undertaken. However, during the COVID-19 pandemic CQC’s primary objective is to act proportionately and support Providers to keep people safe during a period of unprecedented pressure on the health and care system.

We shall continue to closely monitor the situation and keep matters under review, including through regular engagement with the provider and partnership agencies. If absolutely necessary CQC will give consideration to the use of inspection and enforcement powers including urgent powers where we have concerns of harm, such as allegations of abuse.

We have served a fixed penalty notice to the provider for failing to comply with a condition of registration at Orchard Lodge. Fines totalling £1250 have been paid as an alternative to prosecution.

We imposed conditions on the provider's registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider.

The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

Follow up

The overall rating for this service is ‘Inadequate’ and the service therefore remains in special measures. This means we will ke

Orchard Lodge provides accommodation in two units called Boldings and Orchard, which are all on one site. Orchard Lodge provides nursing and personal care for up to 33 people who may have a learning disability, physical disabilities and complex health needs. Most people had complex mobility and communication needs. At the time of our inspection there were 17 people living at Orchard Lodge.

Orchard Lodge is owned and operated by the provider Sussex Healthcare. Services operated by the provider have been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns raised, the provider is currently subject to a police investigation. The investigation is ongoing and no conclusions have yet been reached.

At the previous inspection in November 2018 we found six breaches of regulation in relation to safe care and treatment, safeguarding service users from abuse, dignity and respect, person-centred care, receiving and acting on complaints and governance. At this inspection we found two breaches had been met in relation to acting on complaints and safeguarding people from abuse, while four regulations continued to be breached.

At this inspection, some improvements were identified and acknowledged although these were not sufficient or wide-spread enough to improve the overall final rating. We found that a number of risks remained. Issues we had identified at the previous inspection in November 2018, had still not improved or been actioned by the provider. Concerns about risks associated with application of NEWS, PEG management, choking, eating and aspiration, repositioning and skin integrity and medicines had all been highlighted to the provider on many occasions at other of their services. This information had not been properly shared or used to improve safety and care at Orchard Lodge.

Orchard Lodge has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. These values were not always seen consistently in practice at the service. For example, some people were not receiving the assistance with communication they needed to be as independent as possible. Orchard Lodge was designed, built and registered before this guidance was published. However, the provider has not developed or adapted Orchard Lodge in response to changes in best practice guidance.

People’s experience of using this service:

The service met the characteristics of Inadequate in the Safe and Well-Led domains and Requires Improvement in the Effective, Caring and Responsive domains. This meant the provider needed to make improvements to people’s support. These are detailed below.

Some aspects of the service remained unsafe. Some people were at risk from harm as risk assessments were not effective in reducing the likelihood of harm and staff had not taken steps to keep people safe.

Learning from incidents had not been consistently implemented.

People's needs and choices were not always assessed so staff knew and understood how to deliver support for them to achieve effective outcomes.

Quality assurance and governance systems were not operating effectively and were not supporting staff and management to understand their responsibilities and ensure that quality performance and risks were properly managed.

Some health needs were not being met safely or effectively.

People were supported in a kind and caring way by staff who knew them well.

People’s relatives told us that the new manager had improved communication with family members about their loved ones’ care and developments at the service.

This inspection identified continued breaches of Regulations 9, 10, 12, and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Rating at last inspection:

At our last inspection in November 2018, the service was rated "Inadequate". Our last report was published in February 2019.

Why we inspected: All services rated as Inadequate are re-inspected within six months of our prior inspection. This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Enforcement:

We imposed conditions on the provider's registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

We imposed conditions on the provider's registration for this location.

Follow up:

The overall rating for this registered provider is 'Inadequate'. The service will remain in special measures. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The 'Inadequate' rating does not need to be in the same question at each of these inspections for us to place services in special measures. This was the sixth inspection since July 2017 where the provider remained in breach of Health and Social Care Regulations.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

In July and November 2017 we identified the care provided as ‘Inadequate’ or ‘Requires Improvement’. In January 2018 we found the provider had not made required improvements and therefore their rating did not improve. In April 2018 the service was again rated as requiring improvement overall, with the ‘Well-led’ domain being rated Inadequate.

At this inspection, some improvements were seen and acknowledged; but these were not sufficient or wide-spread enough to improve the final rating. The overall rating has reduced to ‘Inadequate’ despite some of people’s experiences and documentation being better in some areas. This is because there was evidence at this inspection that risks to people’s safety remained; and that similar themes had been raised at our last inspection of Orchard Lodge and at several others of the provider’s services. This showed that information about risk was not being appropriately used or shared between services for the purpose of driving improvement. The failure by the provider to fully address these known and significant risks has led to the rating of the Safe section being reduced to ‘Inadequate’ as a result.

The service will remain in special measures. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This was the fifth inspection since July 2017 where the provider remained in breach of Health and Social Care Regulations.

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Orchard Lodge has not had a registered manager since April 2017. Since that time there had been four separate managers who had submitted, but later withdrew their applications to become registered with the CQC. 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.

Orchard Lodge is a residential care home that also provides nursing care. 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.

Orchard Lodge provides accommodation in two units called Boldings and Orchard East, which are all on one site. Orchard Lodge provides nursing and personal care for up to 33 people who may have a learning disability, physical disabilities and complex health needs. Most people had complex mobility and communication needs. At the time of our inspection there were19 people living at Orchard Lodge.

Orchard Lodge has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. Orchard Lodge was designed, built and registered before this guidance was published. However, the provider has not developed or adapted Orchard Lodge in response to changes in best practice guidance. Had the provider applied to register Orchard Lodge today, the application would be unlikely to be granted. The model and scale of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs.

We continued to find that known risks to people had not been appropriately minimised. This included risks related to percutaneous endoscopic gastrostomy (PEG) feeding, constipation, skin care and aspiration. Lessons had not been learned effectively in these areas, which had all been raised at previous inspections.

Incidents when people had experienced harm or risk of harm had not consistently been referred to the local safeguarding authority, so they could decide whether an independent investigation should happen.

People’s health care needs were not always managed effectively. Some care records were confusing or out of date, creating a risk people would not receive the right care or treatment.

Staff were not always mindful of treating people with dignity and respect and people’s communication needs and right to accessible information had not been fully considered. The response to complaints was not always effective because action was not taken promptly to address them.

Activities had improved overall but further work was needed to involve all people as fully as possible.

There had been insufficient oversight by the provider to identify the concerns found at this inspection. This resulted in continued breaches of Regulation and the safety and quality of the service being compromised.

Medicines were managed safely and the service was clean and fresh. Any environmental and fire risks were routinely monitored and assessed.

There were sufficient, trained staff deployed to meet people's needs and there was a robust recruitment system in operation.

MCA assessments had been carried out and most best interest decisions had been documented. DoLS authorisations were monitored and reapplication dates recorded.

People were supported to receive adequate nutrition and hydration. People’s likes and dislikes were thoughtfully documented and staff knew people well. Religious and spiritual needs were met. People and relatives were given opportunities to be involved in their care at resident and care plan review meetings.

Staff said they felt supported by senior managers and worked well together. Relatives gave positive feedback about staff and the care they delivered.

Statutory notifications were made to CQC appropriately and the provider had displayed their CQC rating in the service and on their website.

At this inspection we found the service was in breach of six of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In July and November 2017 we identified the care provided as ‘Inadequate’ or ‘Requires Improvement’. At the last inspection on 8 and 9 January 2018 we inspected Orchard Lodge and found the provider had not made required improvements and therefore their rating did not improve. The provider informed us of the action they were taking to improve the quality of care they provided.

The overall rating for this service is ‘Requires improvement’. However, this service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.This was the fourth inspection since July 2017 where the provider remained in breach of Health and Social Care Regulations.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Orchard Lodge has not had a registered manager since April 2017. Since that time there had been three managers who submitted and later withdrew their applications to become the registered manager. At this inspection, there was a new manager in post who had submitted an application to become a registered manager. They had been working at the home for two weeks. 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.

Orchard Lodge is a residential care home that also provides nursing care. 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.

Orchard Lodge provides accommodation in two units called Boldings and Orchard East, which are all on one site. Orchard Lodge provides nursing and personal care for up to 33 people who may have a learning disability, physical disabilities and complex health needs. Most people had complex mobility and communication needs. At the time of our inspection there were 21 people living at Orchard Lodge. People living at the service had their own bedrooms and en-suite bathrooms. In each unit, there was a communal lounge and separate dining room. The home environment was spacious throughout and adapted to meet the needs of people who use wheelchairs. The home was decorated with pictures and photographs of people living at the home. Orchard Lodge also offers hydrotherapy facilities.

Orchard Lodge has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. Orchard Lodge was designed, built and registered before this guidance was published. However the provider has not developed or adapted Orchard Lodge in response to changes in best practice guidance. Had the provider applied to register Orchard Lodge today, the application would be unlikely to be granted. The model and scale of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs.

These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service should be able to live as ordinary a life as any citizen, but this was not always the case for people. Orchard Lodge is a large clinical setting rather than a small-scale homely environment. Orchard Lodge is geographically isolated on a campus in rural Horsham with many people having moved to Orchard Lodge from other local authority areas and therefore not as able to retain ties with their local communities. For some people, there were limited opportunities to have meaningful engagement with the local community amenities. Some people had limited contact with specialist health and social care support in the community due to specialist staff (physiotherapy, dietician) that were employed by the provider. Most people's social engagement and activities took place either at Orchard Lodge or at another service operated by the provider, such as the provider's day centre.

At the last three inspections we remained significantly concerned about how the provider managed risks on people’s behalf. At this inspection we noted some improvements had been made. However, further work was required to ensure the provider had done everything reasonably practicable to mitigate risks associated with people’s physical health conditions. This included ensuring all care records demonstrated people’s moving and transferring needs were being met.

At previous inspections, we found the provider had failed to ensure that all staff had received the appropriate training prior to supporting people living at the home. This included agency registered nurses. At this inspection we found the provider had taken action and agency registered nurses had attended training courses relating to people’s physical health conditions. However, we also found not all agency registered nurses, routinely used by the provider, had attended learning disability training.

In November 2017, the provider was in breach of Regulations associated with promoting and respecting people’s dignity. At this inspection, we observed the provider remained in breach of Regulations as caring approaches were not consistently applied by all staff when supporting people.

Personalised care was not always provided in response to people’s individual needs. Activities were routinely offered to people. However, we found these were not always meaningful and appropriate for all people.

Monitoring tools were not consistently effective. They had failed to ensure there were appropriate systems implemented to assess, monitor and improve the quality of the service.

People's consent to care and treatment was gained in line with the requirements of the Mental Capacity Act 2005. People were supported to have choice and control of their lives and staff do support them in the least restrictive way possible; the policies and systems in the service do support this practice.

Staff received supervisions and appraisals and they found the new manager’s approach supportive. People were provided choices on a daily basis regarding what food they ate and clothes they wore and complaints were managed effectively. The provider sought feedback from people and their relatives regarding the care received.

Equipment risks such as hoist equipment, wheelchairs and legionella checks were managed effectively through prompt and regular servicing. Staff employed by the home underwent a thorough safe recruitment process and were provided opportunities to contribute to the development of the home. People and their relatives were invited to provide their views on the care and treatment received formally through surveys.

The manager had sought information about the new Key Lines of Enquiry (KLOE) which the Commission introduced from 1 November 2017. They were keen to improve the quality and safety of care provided to people living at the home.

At this inspection we found the service was in breach of five of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

The service has been subject to a period of increased monitoring and support by commissioners. The service has been the subject of multiple safeguarding investigations by the local authority and partner agencies. As a result of concerns raised, the provider is currently subject to a police investigation. West Sussex Safeguarding Adults Board have also published information on their website regarding safeguarding concerns about Orchard Lodge.

In July 2017 we identified areas of care as ‘Inadequate’ or ‘Requires Improvement’. The service received an overall rating of Inadequate, so the service was placed into 'special measures'. On 2, 3 and 6 November 2017 we inspected Orchard Lodge and found the provider had not made required improvements and therefore their rating did not improve. Shortly after the inspection we wrote to the provider and informed them that despite some improvements the Care Quality Commission remained significantly concerned about some areas of care and safety which had yet to improve and highlighted some new potential safety risks for people living at the home. The provider informed us of the action they were taking to improve the quality of care they provided.

At this inspection the provider had not improved the rating for Safe and Well-led from Inadequate because to do so requires consistent good practice over time and we found new areas of potential risk for people. We will check this during our next planned comprehensive inspection.

The overall rating for this service is ‘inadequate’ and the service therefore remains in ‘special measures.’ Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

This service will remain in special measures and continue to be kept under review by CQC and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months. If there is not enough improvement, so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This could lead to cancelling their registration, or to varying the terms of their 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.

At the last inspection we found systems to assess and monitor the service were in place, but they were not effective. Shortly after the inspection the provider wrote to us to inform us of the action they were taking. At this inspection we continued to find they were not sufficiently robust as they had not ensured a delivery of consistent, high quality care across the service or pro-actively identified all the issues we found during the inspection. This included checks made on how medicines were managed and a lack of analysis and monitoring of the skills and competencies of agency registered nurses.

At the last inspection we found a lack of accessible specific guidance in relation to aspects of people's healthcare needs. The provider wrote to us and told us the actions they were taking. At this inspection we found some aspects of care planning had improved. However, care records did not demonstrate people had received the safe care and treatment as referred to in their care plans. This included gaps within daily records when supporting people with their continence needs, the application of prescribed topical creams and moving and transferring needs.

Orchard Lodge has not had a registered manager since April 2017. Since that time there had been two managers who submitted and later withdrew their applications to become the registered manager. At this inspection, there was a manager in post who had submitted an application to become 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.

Orchard Lodge is a residential care home that also provides nursing care. 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.

Orchard Lodge provides accommodation in three units called Boldings, Orchard East and Orchard West, which are all on one site. Orchard Lodge provides nursing and personal care for up to 33 people who may have a learning disability, physical disabilities and complex health needs. Most people had complex mobility and communication needs. At the time of our inspection there were 24 people living at Orchard Lodge. People living at the service had their own bedrooms and en-suite bathrooms. In each unit, there was a communal lounge and separate dining room. The units shared transport and offered 24-hour nurse support and a social and recreational activities programme. The home environment was spacious throughout and adapted to meet the needs of people who use wheelchairs. The home was decorated with pictures and photographs of people living at the home. Orchard Lodge also offers a spa and hydrotherapy facilities.

Orchard Lodge has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. Orchard Lodge was designed, built and registered before this guidance was published. However the provider has not developed or adapted Orchard Lodge in response to

changes in best practice guidance. Had the provider applied to register Orchard Lodge today, the application would be unlikely to be granted. The model and scale of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs.

These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service should be able to live as ordinary a life as any citizen, but this was not always the case for people. Orchard Lodge is a large clinical setting rather than a small-scale homely environment. Orchard Lodge is geographically isolated on a campus in rural Horsham with many people having moved to Orchard Lodge from other local authority areas and therefore not as able to retain ties with their local communities. For some people, there were limited opportunities to have meaningful engagement with the local community amenities. Some people had limited contact with specialist health and social care support in the community due to specialist staff (physiotherapy, dietician) that were employed by the provider. Most people's social engagement and activities took place either at Orchard Lodge or at another service operated by the provider, such as the provider's day centre.

Equipment risks such as hoist equipment, wheelchairs and legionella checks were managed effectively through prompt and regular servicing. Staff employed by the home underwent a thorough safe recruitment process and were provided opportunities to contribute to the development of the home. People and their relatives were invited to provide their views on the care and treatment received formally through surveys.

At the last inspection in November 2017 we identified four breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this focused inspection we identified two continued breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This inspection was a comprehensive inspection brought forward due to concerns shared with the Commission from the local authority safeguarding team. The concerns were regarding how a person was supported when they became acutely unwell prior to their admission to hospital. Our inspection did not examine the specifics of this incident and the allegation. However, we used the information of concern raised by partner agencies to plan areas we would inspect and to judge the safety and quality of the service at the time of the inspection.

The service had been subject to a period of increased monitoring and support by commissioners. The service has been the subject of multiple safeguarding investigations by the local authority and partner agencies. As a result of concerns raised, the provider is currently subject to a police investigation. West Sussex Safeguarding Adults Board have also published information on their website regarding safeguarding concerns about Orchard Lodge. Between May and November 2017 we have inspected a number of Sussex Health Care locations in relation to concerns about variations in quality and safety across their services and will report on what we find.

At this inspection we also focused on the areas of care we identified as 'Inadequate' or 'Requiring Improvement' at the last inspection in July 2017. The service received an overall rating of Inadequate, therefore the service was placed into ‘special measures’. At this inspection we could not improve the rating for Safe and Well-led from Inadequate because to do so requires consistent good practice over time and we found new areas of potential risk for people. We will check this during our next planned comprehensive inspection.

This service will remain in special measures therefore continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration, or to varying the terms of their 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.

At this inspection there was a manager in post who had commenced their application to become 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.

Orchard Lodge provides accommodation in three units called Boldings, Orchard East and Orchard West, which are all on one site. Orchard Lodge provides nursing and personal care for up to 33 people who may have a learning disability, physical disabilities and complex health needs. Most people had complex mobility and communication needs. At the time of our inspection there were 27 people living at Orchard Lodge and one person receiving short term care.

People living at the service had their own bedrooms and en-suite bathrooms. In each unit, there was a communal lounge and separate dining room where people could socialise and eat their meals if they wished. The units shared transport for access to the community and offered 24-hour nurse support and a social and recreational activities programme. The home environment was spacious throughout and adapted to meet the needs of people who use wheelchairs. The home was decorated with pictures and photographs of people living at the home. Orchard Lodge also offers a spa and hydrotherapy facilities.

Orchard Lodge has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. Orchard Lodge was designed, built and registered before this guidance was published. However the provider has not developed or adapted Orchard Lodge in response to changes in best practice guidance. Had the provider applied to register Orchard Lodge today, the application would be unlikely to be granted. The model and scale of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs.

These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service should be able to live as ordinary a life as any citizen, but this was not always the case for people. Orchard Lodge is a large clinical setting rather than a small-scale homely environment. Orchard Lodge is geographically isolated on a campus in rural Horsham with many people having moved to Orchard Lodge from other local authority areas and therefore not as able to retain ties with their local communities. For some people, there were limited opportunities to have meaningful engagement with the local community amenities. Some people had limited contact with specialist health and social care support in the community due to specialist staff (physiotherapy, speech and language) that were employed by the provider. Most people's social engagement and activities took place either at Orchard Lodge or at another service operated by the provider, such as the provider's day centre.

At the last inspection we found people may have been exposed to risk, as incidents and safeguarding concerns had not been raised to the management team or external agencies such as the West Sussex Safeguarding team. At this inspection improvements had been made and care staff had a better understanding of their role and responsibilities when protecting people. However, one incident had not been referred to external agencies by the management team. We made a recommendation regarding further improvements the provider needed to make to ensure people were consistently protected from risk of harm.

Some people living at the home required enteral feeding and had a percutaneous endoscopic gastrostomy (PEG) feeding tubes fitted. A PEG allows nutrition, fluids and medicines to be put directly into the stomach, bypassing the mouth and oesophagus. At the last inspection we identified a lack of specific guidance available for staff surrounding PEG management. At this inspection we found specific guidance was in place to guide staff accordingly. However, we found a lack of accessible specific guidance in relation to other aspects of people’s healthcare such as supporting people with their conditions such as asthma and bowel management. This had an associated increased level of risk due to the number of agency nurses working at the home and the lack of monitoring of their skills, abilities and training attended by the management team.

We identified gaps in knowledge amongst staff regarding which people had Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) status. The provider told us the action they would take to minimise further risks to people. Policies and procedures were in place and medicines were managed, stored, given to people as prescribed and disposed of safely. However, we found gaps in guidance available for staff when applying prescribed topical creams to people with various skin conditions.

At this inspection we observed occasions where staff did not give due consideration to people's dignity and their right to privacy was not always respected.

At the last inspection we found systems to assess and monitor the service were in place, but they were not effective. Shortly after the inspection the provider wrote to us to inform us of the action they were taking. At this inspection we continued to find they were not sufficiently robust as they had not ensured a delivery of consistent high care across the service or pro-actively identified all the issues we found during the inspection.

At the last inspection we found concerns regarding how staff were deployed particularly in Orchard West. Since the last inspection the provider took action and had increased staffing levels and there were now enough staff deployed to meet people’s needs, therefore the legal requirement had now been met.

People and their relatives were involved in their own care as much as they were able to be. Environmental risks such as hoist equipment, wheelchairs and legionella checks were managed effectively through prompt and regular servicing. Staff employed by the home underwent a thorough safe recruitment process. People were offered activities and complaints were managed in line with the providers policy.

At the last inspection in July 2017 we identified three breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and rated the service as Inadequate. The provider wrote to us to inform us of the action they were taking. At this inspection we identified four breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and remains rated as overall Inadequate.

Since the inspection we have received an updated action plan from the provider which we have referred to in the Well-led section of this report.

The inspection was bought forward as we had been made aware that following the identification of risks relating to people's care, the service had been subject to a period of increased monitoring and support by commissioners. The service has been the subject of 8 safeguarding investigations by the local authority and partner agencies. As a result of concerns raised, the provider is currently subject to a police investigation. West Sussex Safeguarding Adults Board have also published information on their website regarding safeguarding concerns about Orchard Lodge. Our inspection did not examine specific incidents and safeguarding allegations which have formed part of these investigations. However, we used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May and August 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

Orchard Lodge provides accommodation in three units called Boldings, Orchard East and Orchard West, which are all on one site. Orchard Lodge provides nursing and personal care for up to 33 people who may have learning disabilities, physical disabilities and sensory impairments. Most people had complex mobility and communication needs. At the time of our inspection there were 28 people living at Orchard Lodge.

People living at the service had their own bedroom and en-suite bathroom. In each unit, there was a communal lounge and separate dining room where people could socialise and eat their meals if they wish. The units shared transport for access to the community and offered 24-hour nurse support and a social and recreational activities programme. The home environment is spacious throughout and adapted to meet the needs of people who use wheelchairs. The home was decorated with pictures and photographs of people living at the home. Orchard Lodge also offers a spa and hydrotherapy facilities however they were not fit for use at the time of our inspection.

A home manager started working at Orchard Lodge in April 2017 and had submitted an application to register with the commission. The service is required by a condition of its registration to have a registered manager. A registered manager is a person who 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. Although the home manager was new to Orchard Lodge they had been working for the provider for 15 years.

At the last inspection in November 2016 the service was found to be complying with legal requirements and was given a rating of ‘Good’. However, at this inspection we found that the quality of safety and care had deteriorated and we identified three breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The information of concern shared with the CQC about specific incidents and safeguarding concerns indicated potential concerns about the management of risk related to complex health conditions (Epilepsy, Asthma and dysphagia (difficulty swallowing), deployment of suitably qualified and skilled staff and care of percutaneous endoscopic gastrostomy (PEG) feeding tubes for people who were not able to take food and drink by mouth. Therefore we examined those risks in detail as part of this inspection.

We found concerns regarding how staff were deployed particularly in Orchard West. There were not enough staff readily available to meet people’s needs and to ensure the safety of people at all times, therefore placing people at risk from harm. You can see what action we told the provider to take at the back of the full version of the report.

All staff were trained in safeguarding adults yet the training was not always implemented in practice whilst supporting people. Staff members told us about five separate incidents which had not been raised or brought to the attention of the current management team. Staff had also not raised the concerns with external agencies such as the West Sussex Safeguarding team for their review. Therefore people may have been exposed to further unnecessary risks which may have had a negative impact on their physical and emotional well-being. You can see what action we told the provider to take at the back of the full version of the report.

We identified gaps in training provided to staff. All people living at the home had a learning disability yet not all staff had received specific training on the subject. A significant amount of people lived with epilepsy however, some staff had never completed epilepsy training and others required an updated course.

We spoke with many staff during our inspection that were unhappy in their work and didn’t feel valued and supported. This was mostly dominated with comments about low staffing levels and the impact this had on people they supported. We found opportunities had been missed to provide all staff with face to face supervision sessions to discuss these issues and concerns. You can see what action we told the provider to take at the back of the full version of the report.

The home used four different nursing agencies to supply nurses to cover gaps within shifts. However, no routine checks were carried out to assess whether each nurse attending the home had current training in key subjects such as epilepsy, learning disabilities and PEG management.

Individual risk assessments had been completed by nurses relating to people’s care to minimise risks associated with their needs. However, we found a lack of specific guidance available for nurses surrounding PEG management. Nurses provided care for ten people who used PEG systems for nutrition, hydration and medicines. This had an associated increased level of risk due to the amount of agency nurses working at the home and the lack of monitoring of their skills and abilities by the management team.

Systems to assess and monitor the service were in place but these were not sufficiently robust as they had not ensured a delivery of consistent high care across the service or pro-actively identified all the issues we found during the inspection. The area manager offered assurances during and after the inspection all concerns and issues identified would be addressed to minimise impact on the people living at the home. You can see what action we told the provider to take at the back of the full version of the report.

Policies and procedures were in place and medicines were managed, stored, given to people as prescribed and disposed of safely. Environmental risks such as hoist equipment, wheelchairs and legionella checks were managed effectively through prompt and regular servicing. Staff employed by the home underwent a thorough safe recruitment process.

Mental capacity assessments carried out by the provider were in line with current legislation. Staff understood how people's capacity should be considered and had taken steps to ensure that people's rights were protected in line with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

There was enough food and drink available and offered to people throughout our inspection at mealtimes and also in-between. The menu offered flexibility to meet the needs of people and their specific dietary requirements. People had access to external health care professionals including GP’s who visited the home weekly. The provider had recently employed a dietician. A physiotherapist was employed by the provider to facilitate sessions to people assessed as needing support with this. They told us they were not able to achieve all planned sessions due to staffing levels we shared this with the provider.

Staff presented as kind and caring and offered supportive interactions with people living at the home. We observed staff responded to personal care needs as they arose and involved them with their own care as much as they were able by offering choices and gaining consent prior to providing support. Staff knew people well, their preferences and people who were important to them. Care plans were personalised and pertinent to the person being written about and reviewed monthly by registered nurses.

People were encouraged to be involved in activities including preparing for a garden party soon to be held at the home. Formal complaints were recorded and actions carried out in line with the provider’s complaints policy.

The provider asked people and their relatives views on the care they received using various methods including satisfaction surveys. Relatives shared mostly positive views on the care their family members received. People were able to receive visits from their relatives and friends whenever they wished at the home.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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

At our last inspection, in September 2015, we found breaches of the regulations in relation to good governance and how the provider had responded to feedback as well as the provider’s failure to display their rating from our inspection in 2014. At this inspection, we found that there had been a great improvement in how the service was managed and delivered. The breaches in regulation had been addressed.

Orchard Lodge provides personal and nursing care for up to 33 people with learning and physical disabilities, including respite places. Most people have complex mobility and communication needs. Orchard Lodge is made up of two purpose built bungalows, Orchard Lodge which consists of two units and Boldings Lodge. At the time of inspection, there were 29 people 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.

People spoke highly of the home. Relatives had confidence in the care provided and said that staff were welcoming.

People had developed good relationships with staff and had confidence in their skills and abilities. They told us that staff were kind and that they treated them respectfully. Staff had received training and were supported by the management through supervision and appraisal. Staff were able to pursue additional training which helped them to improve the care they provided to people.

Staff responded quickly to changes in people’s needs and adapted care and support to suit them. Were appropriate, referrals were made to healthcare professionals, such as the GP or Dietician, and advice followed.

People were involved in planning their care and in making suggestions on how the service was run. Since our last inspection, action had been taken to improve how people were supported with the use of communication systems and aids. Communication passports had also been devised and were available to staff and visitors to enable better communication with people. A new Speech and Language Therapist (SALT) had been employed on full-time hours by the provider. They told us that their initial focus would be on further improving communication support and guidelines.

Staff understood how people’s capacity should be considered and had taken steps to ensure that people’s rights were protected in line with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS).

People felt safe at the service and there were enough staff to respond to their needs. Staff understood local safeguarding procedures. They were able to speak about the action they would take if they were concerned that someone was at risk of abuse. Risks to people’s safety were assessed and reviewed. People received their medicines safely.

People enjoyed the meals at the service and were offered choice and flexibility in the menu. The chef had a good understanding of people’s likes and dislikes and took great care to provide specific dishes or supplies to meet people’s requests. A variety of activities were provided and a driver had been employed which helped to facilitate more regular outings. The premises were purpose built and provided space for people to move around freely, to relax and to enjoy outdoor spaces.

There was strong leadership within the home. The registered manager monitored the delivery of care and the provider had a system to monitor and review the quality of the service. Suggestions on improvements to the service were welcomed and people’s feedback encouraged. One care assistant said, “(Registered manager) is willing to change things, she’ll think about anything you suggest. Our ideas are more valued and I know that I can go to her”.