The Care Quality Commission (CQC) has downgraded the overall rating of Orchard House in Oxfordshire from outstanding to inadequate and placed it in special measures to protect people following an inspection in April.
This unannounced focused inspection was undertaken after CQC received information of concern in relation to the safety and management of the service.
Orchard House is a neurological rehabilitation centre providing specialist community-based transitional rehabilitation for people with brain and spinal injuries, stroke, minimally conscious states, and a range of progressive neurological conditions. The service could support up to 11 people. There were ten people living at Orchard House at the time of the inspection.
As well as the decline in their overall rating, how effective, responsive and well-led the service is has also dropped from outstanding to inadequate. How safe the service is has declined from good to inadequate. Caring has dropped from outstanding to requires improvement.
Following the inspection CQC served two warning notices, requiring the service to improve its management and assessment of risk and make sure people living in the service receive safe care and treatment.
CQC has placed the service into special measures in order to focus the provider’s attention on making rapid and widespread improvements. CQC will closely monitor the service during this time to keep people safe will inspect again to assess if improvements are made.
Amy Jupp, CQC deputy director of operations in the south, said:
“During our inspection of Orchard House, we found the provider had failed to make sure there was a consistent oversight of the service to monitor and manage the risks relating to the health, safety and welfare of people living there.
“Previous poor leadership of the service meant that some safe practices had lapsed and people weren’t protected from the risk of abuse, avoidable harm or allowed to have maximum choice and control of their lives.
“We found examples where poor care was affecting the wellbeing of people who lived in the service. For example, people couldn’t access pain relief medication when needed, because evening staff weren’t trained to administer medicines. This meant people wouldn’t be able to access pain relief medication from 8pm until 7am. The provider had previously been told about this, and it is unacceptable that people have been left in pain because of training issues.
“We also found the service’s quality team had recently spent time working on updating peoples care plans. When we reviewed these care plans we found them unfinished and they contained incorrect information, such as the names of other people and incorrect diagnosis.
"The steep decline in these standards isn’t good enough and we’ve issued two warning notices to the provider at Orchard House to help them to concentrate on the areas we want to see significant and rapid improvements, as nobody should ever have to live in a service which is unsafe.
“We will continue to monitor Orchard House closely to ensure the necessary improvements are made urgently to keep people safe and free from harm. If we aren’t assured people are receiving safe care, we won’t hesitate to take further enforcement action, even if this results in closure of the service.”
Inspectors found:
- Systems to keep people safe weren’t effective to identify and prevent risks to people's safety
- Where it was appropriate, people hadn’t been supported or involved in developing their end-of-life care plans to record their wishes or preferences
- Records showed there had been a delay in reporting a number of safeguarding incidents to the appropriate authority and CQC
- People weren’t always treated with dignity and respect and their independence wasn’t promoted
- People weren’t always supported by enough staff to meet their needs
- There were environmental risks to people's safety with furniture in a deteriorated state which was rusty or had peeling paint
- The provider hadn’t followed best practice in relation to infection prevention and control
- There were gaps in the record sheets for cleaning. The manager said the cleaner had left and it was up to staff to clean the premises
- People weren’t always supported to have maximum choice and control of their lives and staff didn’t always support them in the least restrictive way possible and in their best interests.