CQC report explained · a nursing home
What the CQC found at Orchid Lawns
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- There were enough staff, and medicines and infection control were handled safely. However, safeguarding incidents were not always reported promptly, and some fluid, medicine and employment records had gaps or inconsistencies.
- Effective?
- Requires improvement
- People received support with food, drink and healthcare, and staff training had improved. Some staff still needed more support with risk management and Deprivation of Liberty Safeguards, and follow-up actions were not always recorded.
- Caring?
- Good
- Staff treated people with kindness, patience, dignity and respect. They offered choices and used relatives' knowledge and people's reactions to understand preferences.
- Responsive?
- Requires improvement
- Care plans and handovers had improved, and people were supported with relationships, interests and end of life care. Some care records still had gaps, complaints had not previously been recorded properly, and some relatives felt people were lonely or needed more help to join activities.
- Well-led?
- Requires improvement
- A new manager had started to improve the service, staff felt more supported and relatives said communication had improved. However, some improvement actions were not complete or fully embedded, and the home remained in breach for delayed incident notifications.
What inspectors found, August 2021
Rated Requires Improvement and no longer in special measures; inspectors found kind care and improvements, but safeguarding reports and some care records were not reliable enough.
This was an unannounced follow-up inspection on 28 June and 9 July 2021. Inspectors spoke with relatives and staff, observed care, checked care and medicines records, and reviewed training and management records.
The home supported 11 people, many with complex needs and advanced dementia. Inspectors found enough staff, safe medicines administration, good infection control, suitable support with food and drink, and kind, respectful care. However, some safeguarding incidents were not reported promptly, and some records were incomplete or difficult to read.
The home was rated Requires Improvement overall. Safe, Effective, Responsive and Well-led were all rated Requires Improvement. Caring was rated Good. The previous overall rating was Inadequate, and the home had been in special measures, but it was no longer in special measures after this inspection.
Kind and respectful care
Inspectors saw staff being patient, kind and respectful. People did not have to wait long when they needed support.
“We saw staff treating people with kindness, showing patience and respecting them in their communication.” from the report
Staffing levels
There were enough staff to meet people's needs and manage risks. Staff attended to people quickly and knew their needs and preferences.
“There were sufficient staff on duty to meet people's needs.” from the report
Food and drink support
People with specialist diets or who needed encouragement received the right support. Staff followed guidance about soft diets and thickened drinks.
“Staff, including the chef had a good awareness of people's dietary needs and were observed to be following the guidance correctly.” from the report
Improved leadership
The new manager had begun putting better systems in place. Staff said they felt happier, listened to and more supported.
“The registered manager had worked with other senior staff members to begin to implement the actions in the improvement plan which was now being implemented at a faster pace.” from the report
Delayed safeguarding reports
seriousTwo recent safeguarding incidents were not reported to the CQC. One was also not reported to the local authority safeguarding team, and another was reported eight days late.
“We found there had been two recent safeguarding incidents which had not been submitted to the CQC.” from the report
Incomplete and unclear records
needs fixingSome fluid records were difficult to read or had gaps. Medicines records were still inconsistent, and body maps did not always show where creams should be applied.
“On occasion some records were difficult to read due to the standard of handwriting and there were some gaps in the recording.” from the report
Improvements not fully embedded
needs fixingThe home had introduced new systems, but some actions were unfinished and staff practice was not yet consistent. The provider was asked to continue improving oversight.
“Other actions were yet to be completed and all actions had yet to be fully embedded into practice.” from the report
- 01How do you now make sure every safeguarding concern is reported to the CQC and local authority without delay?
- 02How are you checking that fluid, medicines and daily care records are complete, clear and accurate?
- 03Which actions from the improvement plan are still unfinished, and when will they be fully embedded?
- 04How will you make sure my relative has regular activities and is not left feeling lonely?
- 05Has the bathroom been repaired, and are people now able to choose between baths and showers?
This was an unannounced follow-up inspection focused on previous required improvements and concerns about safeguarding reports, with infection prevention and control also checked; all five key questions were rated. This explanation was written from the published report of 10 August 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2021
Rated Inadequate and placed in special measures; inspectors found serious risks, poor staffing and weak leadership.
This was an unannounced comprehensive inspection. Inspectors visited on 18 and 19 November 2020, with inspection activity continuing until 30 November. They spoke with staff, relatives and health professionals, and reviewed care plans, risk records, medicines records, rotas and management records.
The home was rated Inadequate overall. Safe, Effective and Well-led were Inadequate. Caring and Responsive both Requires Improvement. Inspectors found people were at risk because risks were not managed well, staffing was inconsistent, staff lacked some important skills, and leaders did not have effective oversight.
There were some positive findings. Infection control arrangements for COVID-19 were effective, people received food suited to their dietary needs on the inspection days, and some relatives described staff as kind and caring. However, care was not always attentive, personalised or dignified, and people had limited meaningful activity.
The rating had fallen from Good at the previous inspection on 29 May 2019. The home was placed in special measures. The provider was asked for an action plan, and CQC said it would monitor progress and re-inspect.
Infection control
Inspectors found effective arrangements to help prevent and control COVID-19. These included testing, appropriate use of protective equipment and measures for visitors and new admissions.
“There were effective systems in place to help prevent and control the spread of COVID 19.” from the report
Dietary needs
Staff and the chef knew about people's dietary requirements and followed swallowing and texture recommendations on the inspection day.
“People were provided with food according to these recommendations on the day of inspection.” from the report
Some kind care
Some relatives gave positive feedback about staff kindness and gentle interactions, although inspectors did not find this was consistent across the home.
“Staff will always acknowledge [person] even if it's just getting down to her level to say hello or touching their hand gently,” from the report
Interim manager
The interim manager received positive feedback from staff. They were described as approachable, willing to listen and helpful with problems.
“The interim manager is very supportive and approachable. They listen and sorts things out.” from the report
Risks and moving people
seriousInspectors found unsafe moving and handling practices, including people being put into slings without evidence of an assessment or care plan. Unexplained bruising was also raised.
“I've seen people put into slings they have not been assessed for and there was no risk assessment or care plan in place to evidence hoisting was required.” from the report
Staffing levels
seriousStaff were not consistently deployed to meet people's needs. Agency staff were used heavily, and some staff said there were too few people to provide timely care.
“The lack of consistent staffing meant staff did not know people well and this impacted on the organisation of the shift.” from the report
Missed medicines
seriousOne person missed a prescribed medicine for five days and another missed blood-thinning medicine for nine days. The checks introduced by management did not identify the second error.
“The error was not noticed for five days.” from the report
Training and dementia support
needs fixingOnly nine of 25 staff had accredited dementia training. Inspectors also found that some staff could not show they understood training about pressure care and other needs.
“Staff did not receive appropriate training to meet people's needs.” from the report
Personalised activity
needs fixingPeople spent long periods disengaged, with little meaningful interaction or activity. Staff were allocated activities when the activities coordinator was unwell, but these were not provided.
“People spent prolonged periods of time disengaged with limited engagement or meaningful interaction.” from the report
Weak oversight
seriousManagement systems did not reliably identify risks or ensure improvements were made. Safeguarding concerns had increased, and some required notifications were not sent to CQC promptly.
“Effective arrangements were not in place to assess and monitor the quality of care provided, to ensure compliance with regulations.” from the report
- 01What action has been taken to make moving and handling safe, including checks that the correct slings and care plans are used?
- 02How many permanent and agency staff are now on each shift, and how do you ensure agency staff know each person's risks and needs?
- 03What system now prevents missed medicines, and how are medicine errors checked and reviewed?
- 04How many staff have completed accredited dementia training, and what training is still outstanding?
- 05What meaningful activities are now available for each person, and how are relatives involved in reviewing their care plans?
This was an unannounced comprehensive inspection covering all five key questions, with infection prevention and control also considered under Safe. This explanation was written from the published report of 13 January 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Orchid Lawns
7 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- August 2021Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2021Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2015Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- February 2012
Report published without a new overall rating.
- October 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 19 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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