CQC report explained · a residential care home
What the CQC found at The Orchard Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, August 2023
Rated Inadequate and placed in special measures; inspectors found serious risks involving medicines, consent, staff training and management.
This was an unannounced focused inspection. Inspectors visited on 13 June 2023, spoke with people, relatives and staff, and checked care records, medicines, training information and management documents.
The home was rated Inadequate for Safe, Effective and Well-led. Inspectors found poor risk management, unsafe medicines processes, missing or unsuitable consent records, gaps in staff training and weak checks on the quality of care.
There were some positive findings. People and relatives said staff were caring and that people felt safe. Infection prevention, visits, food and drinks were also managed well in the areas checked. However, the overall rating changed from Requires Improvement to Inadequate because the provider had not made enough progress since the previous inspection.
Caring staff
People and relatives told inspectors that staff were caring and kept people safe.
“Staff always make me safe. They are good to me.” from the report
Infection prevention
Inspectors were assured that infection prevention measures, personal protective equipment and visiting arrangements were being managed safely.
“We were assured that the provider was using PPE effectively and safely.” from the report
Poor risk management
seriousImportant risks were not properly assessed or monitored. Inspectors found water systems were not checked regularly, showers were too hot and some environmental risks had not been assessed.
“Systems had not been established to assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Unsafe medicines practice
seriousA person was supported to chew medicines without evidence that a healthcare professional had confirmed this was safe. Guidance for medicines given when needed was also unavailable.
“People were not always supported with their medicines in a safe way.” from the report
Consent and restrictions
seriousMental capacity assessments and best-interest decisions were often missing, incomplete or not specific to the decision. One legal authorisation to deprive a person of their liberty had expired.
“The home was not working within the principles of the MCA.” from the report
Gaps in staff training
seriousSome staff, particularly at night, did not have training in medicines or people’s medical and wellbeing needs. Not all staff had completed learning disability or autism training.
“The provider failed to ensure their staff received appropriate training.” from the report
Weak management checks
seriousAudits did not identify serious problems, incidents were not always recorded or investigated, and the provider had not acted sufficiently on earlier recommendations.
“Audits were minimal and ineffective to assure safe care delivery and environmental safety.” from the report
- 01What has been done to check and control water temperatures and other environmental risks, including the missing window restrictors?
- 02How are medicines now stored, administered and recorded, including medicines given when needed and any medicines that are chewed?
- 03Which people have current mental capacity assessments, best-interest decisions and valid legal authorisations where needed?
- 04What training has every staff member completed, especially night staff, in medicines, safeguarding, learning disabilities, autism and people’s health conditions?
- 05Who is currently responsible for managing the home, and how are audits and incident reviews now identifying and correcting problems?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their ratings were not given in this report. This explanation was written from the published report of 3 August 2023 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, April 2022
The Orchard Care Home is rated Requires Improvement; inspectors found kind care but gaps in infection control, medicines guidance and management oversight.
This was an unannounced focused inspection on 8 and 16 March 2022. Inspectors reviewed safe, effective and well-led care because of concerns about management and decision-making. They spoke with people, relatives, staff and professionals, observed care, and checked records, medicines and training information.
The home was clean and people said they felt safe. Staff knew people well, managed individual risks and provided kind, respectful care. However, masks were not always used correctly, some medicines records and guidance were incomplete, and there was no manager in post.
Inspectors also found routines that did not clearly give people enough choice and control. Training records were incomplete, best-interest decisions were not always documented, and quality checks did not identify important problems. The overall rating changed from Good to Requires Improvement.
Kind and respectful care
People received compassionate care. Staff understood people's communication needs and protected their privacy and dignity.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Managing individual risks
Staff knew people's individual needs and managed risks linked to safety and medical conditions well.
“Risks associated with people's safety and individual medical needs were assessed and managed well.” from the report
Clean environment
The home was clean and hygienic. People were involved in cleaning activities.
“The premises looked very clean and hygienic. People participated in the cleaning of the home” from the report
Support from relatives
Relatives said they were involved in care planning and decisions and were kept informed about health and appointments.
“Relatives said they and their loved ones were involved in care planning and reviews, which included reviewing risk.” from the report
Infection control
seriousStaff did not always use masks correctly in all areas. Infection control policies were out of date and not all relevant training had been completed.
“The provider had failed to do all that was practicable to reduce the risk of infection.” from the report
Medicines guidance and records
needs fixingThere was no clear guidance or recording system for some over-the-counter medicines. A medicine stored in a person's room did not have checks to show it was kept at a safe temperature.
“there was no guidance in place for staff to know when to administer these and there was no documentation for them to record when they had been administered.” from the report
No manager and weak oversight
seriousThere had been no consistent manager for several months. Audits did not identify problems with medicines, PPE or infection control.
“Without a manager effective auditing and quality monitoring processes were not in place.” from the report
Choice and daily routines
needs fixingSet routines applied to everyone, and inspectors were not assured they were in each person's best interests. Hygiene records were completed several days in advance.
“Routines in place meant we were not assured people were living empowered lives of their choosing.” from the report
Training and decision records
needs fixingRecords did not show that all staff had completed relevant training. Some decisions made for people were not clearly supported by best-interest documentation.
“We recommend the provider ensure all staff have completed relevant training and all decisions that are being made on behalf of someone are being assessed and documented in line with legislation.” from the report
- 01Who is currently managing the home, and how are quality checks being carried out while the management arrangements are changing?
- 02What has been changed about mask use, infection control policies and staff training since the inspection?
- 03How are over-the-counter medicines now authorised, recorded and safely stored?
- 04How does the home make sure daily routines are based on each person's choices and best interests?
- 05How are best-interest decisions and staff training now documented and checked?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and previous ratings were used. This explanation was written from the published report of 15 April 2022 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 The Orchard Care Home
4 rated inspections over 8 years: the service has slipped, from Good to Inadequate.
- August 2023Inadequatecurrent ratingdown from Requires improvementSafe: InadequateEffective: InadequateCaring: GoodResponsive: GoodWell-led: Inadequate
- April 2022Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- February 2019Goodstayed GoodSafe: GoodEffective: GoodWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- November 2013
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 17 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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