Orchard House Care Home

Orchard House is a care home providing personal and nursing care to 47 people aged 65 and over at the time of the inspection. The service can support up to 67 people.

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

There were not always enough staff working in one area of the home and this put people at risk of not receiving care when they needed it.

People were happy with the care home and the staff that provided their care.

People felt safe living at the home and staff knew how to report possible harm. Staff assessed and reduced risks as much as possible, and there was equipment in place to help people remain as independent as possible. The provider obtained key recruitment checks before new staff started work.

People received their medicines and staff knew how these should be given. Medicine records were completed accurately and with enough detail. Staff used protective equipment, such as gloves and aprons.

Systems to monitor how well the home was running were carried out. Concerns were followed up to make sure action was taken to rectify any issues. Changes were made where issues had occurred elsewhere, so that the risk of a similar incident occurring again was reduced. People were asked their view of the home and action was taken to change any areas they were not happy with.

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 requires improvement (report published 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection there had been improvement in previous areas of concern but there was a breach of regulation in another area.

Why we inspected

We carried out an unannounced comprehensive inspection of this service between 10 and 12 September 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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.

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 remained requires improvement. 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 House on our website at www.cqc.org.uk.

Enforcement

We have identified a breach in relation to staffing levels at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Orchard House is a care home providing personal and nursing care for up to 67 older people in one purpose-built two storey building. At the time of this inspection 51 people were living at the service.

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

Risks to people were not always identified or reported and acted upon. Staff did not always complete assessments to manage the effects of known risks for such things as challenging behaviour, leaving medicines for people to take or locks on the outside of room doors. Staff did not always report possible safeguarding incidents to a senior manager, which did not make sure that referrals were made to the local authority safeguarding team.

Staff did not always keep care records up to date or have care plans in place. This meant that staff did not have guidance on how to support people’s needs, and there was not always a clear strategy to manage these. People were unhappy with the amount of activities that were provided. Staff missed opportunities to spend time with people, who spent periods unoccupied. We have made a recommendation about developing activities for people with dementia.

Systems to monitor how well the home was running were carried out but did not always identify actions, responsibilities or follow up when issues were identified. There was a lack of oversight of the service by the provider and responsibilities were placed on a frequently changing management team for improvement.

There were enough staff available to meet people’s care needs. The provider obtained most key recruitment checks before new staff started work. Staff received training and supervision, which supported them to carry out their roles, although not all staff following this information and guidance.

Staff supported people with meals and drinks. They used protective equipment, such as gloves and aprons to promote safe hygiene practices. Staff followed advice from health care professionals and made sure they asked people’s consent before caring for them.

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

People liked the staff that cared for them. Staff were kind and caring, they involved people in their care and made sure people’s privacy was respected.

There was a complaints procedure in place, and complaints were investigated and responded to appropriately.

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 requires improvement (published 6 October 2018). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections and inadequate at the inspection prior to these.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to assessing risks to people, keeping people safe from harm, and assessing and monitoring the service. Please see the safe, caring, responsive and well-led sections of this full report.

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.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Orchard House is a ‘care home’. 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 House accommodates up to 67 people in one purpose built property. People were accommodated and cared for over both floors of the building. One floor specialised in providing care to people living with dementia. There were 48 people living at the home at the time of our visit. There is a condition on the registration of this care home that there is a registered manager in post. There was no registered manager in post and there had been no registered manager for nine months. However, there was a manager who was in the process of applying to the Commission for registration.

At our previous inspection in May 2017 we identified two breaches of regulation in regard to keeping people safe from harm and assessing and managing risk. Following that inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question of Safe to at least Good. The home was rated as Requires Improvement, which was also the rating for the inspection before that in May 2016. At this inspection the service remains Requires Improvement. The risk to one person, however, had not been addressed and this resulted in an injury to the person. Although we could see that there was an overall improvement we found a continued breach of one regulation. We also had concerns in relation to the provider's overall monitoring and oversight of this care home, and this has resulted in a breach of another regulation. The provider’s monitoring process looked at systems throughout the home, but was not overseen adequately to ensure it was completed accurately, properly assessed the quality of records or that all trends were identified.

Safeguarding referrals were made to the local authority safeguarding team when this was required. People felt safe and staff knew how to respond to possible harm. There had been an improvement in how risks to people were assessed, although this work had not been completed.

Lessons had been learnt about accidents and incidents and these were usually shared with staff quickly to ensure changes reduced risks to people. There were enough staff who had been recruited properly to make sure they were suitable to work with people. The deployment of staff however, meant that they were not always available when people needed assistance. Medicines were stored and administered safely, and records were completed correctly. Regular cleaning made sure that infection control was maintained and action was taken to address issues.

People were cared for by staff who had received the appropriate training and had the skills and support to carry out their roles. People received a choice of meals, which they liked, and staff supported them to eat and drink. People were referred to health care professionals as needed and staff followed the advice professionals gave them. Adaptations were made to ensure people were safe and able to move around their home as independently as possible. Staff members understood and complied with the principles of the Mental Capacity Act 2005 (MCA). People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff were caring, kind and treated people with respect. People were listened to and were involved in their care and what they did on a day to day basis. People’s right to privacy was maintained by the actions and care given by staff members.

People’s personal and health care needs were met. There was an improvement in the quality of information written in care plans, but work remained to ensure all of these provided staff with guidance in how to meet people’s needs. There were activities for people to do and take part in but people were not able to go out of the home. A complaints system was in place and complaints were investigated and responded to appropriately. Staff gathered information about people’s end of life wishes, so that they could support and care for them in the right way.

Staff worked well together and felt supported by the management team, which promoted a culture for staff to provide person centred care. People’s views were sought and changes made if this was needed.

We found a breach of Regulation 12 and Regulation 17 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.

Further information is in the detailed findings below.

This comprehensive inspection took place on 10 May 2017 and was unannounced.

At the last inspection on 11 May 2016 there was a breach of the legal requirements found. We found that improvements were needed to ensure that people were protected from harm through appropriate referrals to the local authority safeguarding team. The provider told us that they would take the required action by 31 July 2016.

During this inspection we found that the provider had made some improvements in relation to the previous breach. However, people were at a continued risk of harm because referrals to the local authority safeguarding team had not been made by staff in a prompt manner.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the home. 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 home is run. The registered manager was not present during this inspection.

Risks to people who lived at the home were identified. However, systems were not in place to assess and manage all risks to people. Staff understood some of the risks but not how to minimise them for people whose behaviour was at times challenging. Staff did not always treat people with care and respect or make sure that their privacy and dignity was respected all of the time.

Staff did not have the information they needed to administer ‘as prescribed’ medication. The provider's policy on administration and recording of medication had not been followed by staff. Audits in relation to medication administration had been completed but were not robust, as they did not always identify all areas of improvement required.

People had not always had their needs assessed and reviewed so that staff knew how to support them and meet their requirements. Some people's care plans contained person centred information which detailed people’s likes and dislikes and how they wished to be supported but others did not.

There was a system in place to record complaints. However, these records had not always included the outcomes of complaints or how the information was to be used by staff to reduce the risk of recurrence.

People were not always supported to have maximum choice and control of their lives. Staff were trained but did not always understand the key principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) or how people were supported to make decisions if they lacked capacity. We saw that appropriate DoLS applications had been made to lawfully deprive people of their liberty. Authorisations in place were for people’s own safety because they were unable to make decisions on where they should live safely.

People were not always kept safe because the number of staff on night duty did not tally with the staffing levels the provider had calculated was necessary to meet people’s needs. The provider had a recruitment process in place and staff were only employed within the home after all essential safety checks had been satisfactorily completed. Staff received an induction when they started work and further training was available for all staff which provided them with the skills they needed to meet people’s requirements.

People were involved as far as practicable, in how their care and support was provided. Staff monitored people’s health and welfare needs and acted on issues identified. People were enabled to access health care professionals when they needed them. People were provided with a choice of food and drink that they enjoyed. People, where required, were given the right amount of support from staff to enable them to eat and drink.

People, relatives and staff were able to provide feedback and information However, this information was not always used to monitor and improve the quality of the service. The management did not always provide an open or fair culture.

Staff meetings, supervision and individual staff appraisals were completed regularly. Staff were supported by team leaders, deputy manager and the registered manager during the day.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

This unannounced inspection took place on 11 May 2016.

At the last comprehensive inspection on 2 and 5 October 2015 this service was placed into special measures by CQC. A breach of seven legal requirements was found and the service was rated as inadequate. After the comprehensive inspection, the provider wrote to us to say what they would do to meet the legal requirements in relation to:

• responding to and reporting allegations of abuse,

• carrying out assessments of, and managing, risks,

• ensuring that the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards were met,

• treating people with care, dignity and respect,

• involving people in the assessment of their care and treatment,

• assessment and monitoring of the service.

During this inspection we found that there was sufficient improvement to take the service out of special measures. We found that the provider had followed their plan which they had told us would be completed by 31 March 2016 to show how the legal requirements were to be met. Some improvements were however still needed.

The service did not have a registered manager. The last registered manager left their position in October 2015. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The provider had appointed a new manager but they had not yet registered with CQC.

Staff were knowledgeable about reporting concerns about people. However, information about suspicions and allegations of harm had not always been reported by the management of the service to the appropriate authorities. This put people at risk of harm and limited those organisations responsible for safeguarding people to act in a timely manner.

The administration and management of medicines was not always undertaken in a safe way. Staff had been assessed as competent but a medication error had taken place prior to this inspection.

The manager and staff understood and worked within the principles of the Mental Capacity Act 2005 and the codes of practice. Appropriate applications had been sought to deprive people of their liberty.

People were cared for by staff who understood them. People were encouraged to be independent and their privacy and dignity was respected by staff. Assessments and management of risks to people, in areas such as falls and medicines administration, were completed.

People were given opportunities to be involved in, and contribute to, how their care needs were met.

People’s health care needs were identified by staff and met by a range of health care professionals including a GP, speech and language therapist and an occupational therapist.

People were supported with their nutritional needs and staff ensured people ate and drank sufficient quantities.

Staff were provided with a formal induction and regular training and support to enable them to undertake their roles.

People knew how to make a complaint. We saw the provider investigated any complaints and made changes to improve the service.

The manager had carried out regular audits to assess what improvements needed to be made.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

As part of this inspection we observed activities taking place, spoke with three people who used the service, the registered manager, and eight members of care staff. We also reviewed records relating to the management of the service which included six care plans and daily records.

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at.

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

Is the service safe?

During the last inspection of Orchard House care home, which we carried out on 20 May 2014, we found improvements were needed in relation to people's care records. During this inspection of 12 August 2014 we found that improvements had been made. People's care records now provided members of staff with full information about people's individual care needs and how these were to be met safely.

We saw that people were kept safe because members of staff knew how to meet people's individual support and care needs.

People who we spoke with were unable to tell us how they were being looked after, but we saw that they were kept safe.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care services. Applications have not needed to be submitted. Relevant staff understand when an application should be made, and how to submit one.

If you want to see the evidence that supports our summary please read the full report. This is a summary of what we found-

Caring?

We talked with people who used the service, their relatives, visitors and staff. People we spoke with demonstrated or indicated to us that they were well cared for and that care staff always treated them with dignity and respect. A variety of activities which were available ensured that people were offered choices on what they wanted to do. Plans of care we looked at were being updated into a new paper hard copy format and some records had not yet been completed. The majority of people we spoke with told us that they had no problems or concerns with the care they were provided with. One relative we spoke with said, "My (relative) is so settled here and has not wanted to leave."

Responsive?

People's care needs had been assessed and some people's plans of care were being updated. Where people's health had changed or required health care support we saw that this had been provided consistently. People were provided with individualised care and support. People had made, and were supported with, their choices on things such as how they preferred their food, the clothing they liked and the time and place they preferred to eat their meals. People were referred to health care professionals where this support was required such as their GP, chiropodist and optician for regular health checks. Where changes were required to people's support needs, we saw that these had been provided.

Safe?

We saw that regular reviews of people's assessed health risks, such as their risk of malnutrition, falls, choking or safe mobility around the home had been completed. Checks completed by the provider and other external regulatory inspections such as those for gas and electrical and water safety had been completed to ensure that the premises were safe for people who used the service, staff and other visitors. Accidents and incidents had been recorded and investigated to ensure that the potential for any recurrence was eliminated or significantly reduced. The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. People living at the service had not been deprived of the liberties. One relative told us, "I have never seen or heard any inappropriate language being used whenever I have visited the home. I visit nearly every day."

Effective?

Our observations of staff supporting people confirmed to us that people had a very positive experience of living at Orchard House. Staff we spoke knew people's care and support needs well and were able to tell us what these needs were. Relatives we spoke with confirmed to us that the needs of their relatives were effectively met in a consistent way. The provider used various quality assurance reviews to assess the quality of care provided and was in the process of providing the 2014 quality assurance survey to people and their relatives.

Well led?

The service is required to have a registered manager in post. At the time of inspection the manager had submitted their application to the Commission for its consideration. The manager was providing effective leadership. This was evidenced by the staff who were providing good quality care based upon the manager's and other senior staff's advice. No safeguarding concerns had been, or needed to be, reported by staff working at the service. Staff we spoke with told us that the manager's door was always open and that they were confident that action would be taken if they had any comments or suggestions to improve the care provided.

People who used the service benefitted from an improved standard and quality of support, care and treatment. Their individual mental, physical and social care needs were assessed. Members of staff had access to an improved standard of care plan guidance to safely and appropriately meet people's support and care needs.

Remedial actions had been taken to improve the standard of training and supervision of staff. The morale of staff had also improved.

People said that they were satisfied with the standard and quality of their care. Improvements were needed, however, to ensure that people living with dementia had their individual support and care needs assessed. Improvements were also needed regarding the standard and quality of care provided to people living with dementia.

Food and drink was provided in sufficient amounts to ensure people were protected from the risks associated with malnutrition and dehydration. People were provided with a range and choices from the menu to suit their individual preferences.

There were systems in place to protect people from the risk of harm. People said they felt safe living at Orchard House.

Arrangements were being made to ensure that all members of staff had up-to-date training. Improvements were needed to ensure that all members of staff were competent and confident to do the work they were requested to do.

There was a suggestion, concerns and complaints system in place for people, their guests and visitors to the home to access. People said they knew what to do if they were unhappy about their support and care but said that they had no cause to make a concern or complaint.