• Care Home
  • Care home

Archived: Orchard Manor Limited

Overall: Inadequate

42 Slaney Road, Walsall, West Midlands, WS3 4BN (01922) 644855

Provided and run by:
C&V Orchard Manor Limited

All Inspections

11 October 2017

During a routine inspection

This unannounced inspection took place on the 10, 11 and 17 October 2017. The inspection was prompted in part by increased notifications from the provider advising us that some people who lived at the home had sustained a serious injury. The information shared with CQC about the incidents indicated potential concerns about the management of people's care needs. This visit was also brought forward following information of concern being shared with us by the local authority. This inspection examined those risks.

Orchard Manor provides accommodation for up to 34 people who require personal care. At the time of our inspection there were 32 people living at the home.

At our last comprehensive inspection visit in November 2016 we rated the service as 'requires improvement' in all the areas we inspected. We found the provider was in breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as people’s rights were not protected through the effective application of the Mental Capacity Act (2005). The provider was in breach of Regulation 12 regarding safe care and treatment because the management of medicines was not safe. In addition the provider was in breach of Regulation 17 relating to the governance of the service. The provider did not have effective systems in place to assess, monitor and improve the quality and safety of the service and had not maintained accurate complete and contemporaneous records in respect of each service user. After our inspection in November 2016 the registered provider sent us an action plan to show how they would meet the legal requirements of the regulations.

We undertook this unannounced inspection on 10, 11 and 17 October 2017 to check the registered provider had followed their own action plan and to monitor their compliance with the legal requirements of the regulations. During this inspection we found widespread and significant shortfalls in the service; which meant people had experienced harm and or had been exposed to the risk of harm. The required improvements had not been made and the service had deteriorated significantly. We asked the registered provider to take immediate action to ensure the safety of people who had been identified as at high and extreme risk of harm. During day one of our inspection we alerted the Local Authority about the serious safeguarding concerns identified. The local authority attended the service following our escalation and a number of health and social care professionals visited the home to carry out reviews. The Local Authority shared our concerns and provided the home with a team of staff to increase their staffing levels to ensure people were kept safe whilst we considered what further action to take.

There was not a registered manager in place and the home was being managed by an acting 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.

At this inspection in October 2017 we found serious concerns about the safety of the service. People were at risk of and at times had been subjected to unsafe and inadequate care and support. Risks to people relating to the management of people’s physical and mental healthcare needs were not always identified, recorded and known to staff. Staff lacked knowledge of those at risk of choking and measures were not in place to minimise this risk. Skin integrity was poorly managed placing people at risk of injures. Clinical observations which could indicate health concerns were not understood and acted upon. People were not protected from harm due to staff not recognising and reporting safeguarding incidents to the local authority. People were at risk of injury due to unsafe moving and handling practices, poor maintenance of equipment and a lack of suitable equipment.

The home was dirty and smelt offensive. The systems in place to ensure good infection control and prevention and the cleanliness of the environment were not adequate. Infection control practices were reviewed by an infection control nurse and found to be unacceptable. There were insufficient staff numbers available to meet people’s needs safely and in a timely manner. We could not be confident people always received their medicines as prescribed.

People were not supported by sufficient number of care staff who had the training, skills and knowledge to support them effectively. People were not supported in a way that protected them from unlawful restrictions. People did not have their rights upheld and protected due to poor understanding and implementation of the Mental Capacity Act.

People did not have their food and fluids intake managed safely when it had been identified that they were of risk of malnutrition and dehydration. Some people did have contact with healthcare professionals to maintain their health, however, staff had not always identified when healthcare support was required and subsequently throughout our inspection we found people whose healthcare needs had not been met. Sometimes people did not receive the appropriate health interventions when needed.

People did not have their privacy and dignity respected and were not always treated compassionately. We found occasions where people were in a distressed, anxious or unkempt state and the inspection team had to intervene. People were not involved in making decisions and choices about their care and support. Staff did not have time to build meaningful

relationships with people. Some language and daily records used by staff to describe people and their care needs was not dignified. People’s individual cultural and language needs were not met and valued.

People did not receive personalised care which met their needs. The majority of care plans did not reflect people’s current needs, and they were not an accurate or helpful tool for staff providing care. Staff did not know what people’s needs were and how support should be provided. People had not received the opportunity to undertake any range of interesting and stimulating activities that they enjoyed. People did not feel that their concerns and complaints were listened to.

Leadership within the home was woefully inadequate and had failed to ensure positive outcomes for people who lived there. People had been placed at risk of significant harm and many had experienced avoidable harm. The registered provider systems in place failed to ensure people received the care and support they needed and had failed to monitor the quality of the service and ensure people were protected from harm. In addition the registered provider had failed to notify us of events as required by law.

The overall rating for this service was 'Inadequate' and the service was therefore placed into 'Special measures'. Services in special measures are kept under review. Following the inspection we took urgent action to cancel the registration of the provider as people were exposed to ongoing risk of harm and the provider failed to make sufficient and timely improvements. At the time of the publication of this report, our action had been completed and there were no longer any people living at the service.

We found that the provider was not meeting all of the requirements of the law. We found multiple breaches in regulations. You can see what action we told the provider to take at the back of the full version of the report.

23 November 2016

During a routine inspection

This unannounced inspection took place on 23 November 2016. At our last inspection visit on 4 February 2016 we rated the service as ‘requires improvement’ in all the areas we inspected. We found the provider was in breach of the regulation regarding ‘need for consent’. We asked the provider to take action to ensure there were arrangements in place to gain people’s consent. When we carried out this inspection although improvements had been made we found the provider was still in breach of the regulation. Orchard Manor provides accommodation for people who require personal care for up to 34 people. At the time of our inspection there were 25 people living at the home.

There was a registered manager in place however they had not been at the home for a number of months and the home was being managed by the deputy 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.

Improvements were needed to the management of medicines to ensure people received their medicines as prescribed. People told us they felt safe and were happy with the support they received from staff. Staff could identify signs of potential abuse and were able to explain what actions they would take to keep people safe. Risks to people were not updated when people’s needs changed and guidance was not available for staff to refer to. People did not always receive support from sufficient numbers of staff which meant on occasions people’s needs were not met in a timely manner.

People were asked for their consent before care and support was provided by staff. Information relating to any restrictions of people’s rights and freedoms were not available. People told us staff had the skills to meet their needs. However training for some staff was not up to date. People told us they had sufficient to eat and drink and had access to healthcare professionals when they needed.

People told us staff were caring but did not always have time to spend with them. Care records were not reflective of people’s needs or risks. People told us there were not enough leisure opportunities and people were not supported to follow any interests or hobbies. People told us their dignity and privacy was maintained and respected by staff. People were confident if they had any concerns or complaints, they would be listened to and the matter resolved.

Staff understood their roles and responsibilities. Quality systems in place to monitor care provided were not effective. Improvements identified at the last inspection had not been implemented.

We found three breaches of the HSCA 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the back of the full version of this report.

4 February 2016

During a routine inspection

This unannounced inspection took place on 4 February 2016. At our last inspection visit on 5 March 2014, the provider was meeting the regulations we looked at. Orchard Manor provides accommodation for persons who require personal care for up to 34 people. At the time of our inspection there were 26 people living at the home.

There was registered manager in place. 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 said they felt safe within the home and were happy with the care they received. Staff knew how to report any concerns and were aware of the provider’s procedure for reporting any issues around people’s safety. People were not always protected from the risk of harm because risk’s had not been clearly identified and managed.

There were sufficient staff on duty to meet the care and support needs of people. People received their medicines as prescribed and appropriate records were kept when medicines were administered.

Some staff were not knowledgeable about the requirements and their responsibilities in relation to the Mental Capacity Act 2005. Assessments of people’s capacity to consent and records of decision had not been completed. People were at risk of having their rights and freedom restricted. Staff did not always ensure they sought people’s consent before providing care.

Staff had received training but not all staff had the skills and knowledge to support people’s specific care needs.

People were supported to have sufficient to eat and drink. However mealtimes were not a positive experience for everyone living at the home. People were supported to access other healthcare professionals to ensure that their healthcare needs were met.

People felt staff were kind and caring however, people’s independence was not fully promoted. People were supported to maintain their interests as far as possible. Care plans were mainly centred around providing for people’s personal care needs. Some plans did not include details of people’s likes, preferences and specific detail for staff to provide individualised care and support.

People were confident if they had any concerns or complaints, they would be listened to and the matter resolved.

People told us the staff; provider and registered manager were approachable. The provider had audit systems to record incidents and accidents. However, we found that there were no processes in place to identify and monitor trends that would improve the quality of care people received.

You can see what action we told the provider to take at the back of the full version of this report.

5 March 2014

During a routine inspection

We completed an inspection on 29 November 2013, where we found the provider was non-compliant with outcome 4: Care and welfare. We found that improvements were needed. We found that some areas of people's needs had not been assessed and some care plans were not fully up to date.

After the inspection, the provider sent us an action plan. This told us the action the provider would take and by what date.

At this inspection we checked whether required improvements had been made to care and welfare issues identified at the last inspection.

During this follow up inspection, we spoke with the registered manager and reviewed three people's care plans.

We found that the provider was now compliant. Care and treatment was planned and delivered in a way that ensured people's safety and welfare.

29 November 2013

During a routine inspection

This was a scheduled inspection. The provider did not know we were visiting. During the inspection we spoke with the manager, care workers and people that lived at the home. We also spoke with two relatives. We spent time observing as some people could not tell us about their experiences.

People told us they were quite happy living at the home. They told us they could make decisions about their life. We saw that people were supported to have their personal care needs met and saw the doctor when they were ill. Some areas of need were not assessed and some plans of care were not fully up to date.

People were provided with a varied menu and they had a choice of meals. People that needed help to eat received the support they needed. People's nutritional needs were assessed and monitored.

The premises were safe for the people that lived there. Some areas of the home would benefit from redecoration.

The provider's recruitment procedures made sure that care workers were suitable to provide care to vulnerable people. All the required checks were completed.

A complaints procedure was available to people that lived at the home. The provider listened to people and acted upon concerns.

11 January 2013

During a routine inspection

During our inspection we spoke with the registered manager and staff on duty.

We completed an inspection on 17th April 2012 where four key outcomes were inspected. The service was found to be compliant with all four outcomes.

We needed to complete a second visit to ensure that overall five outcomes had been inspected at this home as part of their scheduled annual inspection.

We looked at outcome12 to establish whether requirements relating to workers were effectively implemented within the home.

One staff member told us, 'We get support when we need it from the manager. We get a lot of training and are always reminded when training needs updating'.

We found that Orchard Manor Limited had effective recruitment and selection procedures in place and that appropriate checks were undertaken before staff began work.

Staff we spoke with told us they had appropriate training to undertake their work competently and had a good level of support from the management team.

We found that Orchard Manor Limited was compliant in this outcome area.

18 April 2012

During an inspection looking at part of the service

Our inspection of 02 February 2012 found that improvements were needed to the service that was being offered. We have taken enforcement action against the provider to protect the health, safety and welfare of the people using this service. The provider wrote to us and told us what they were going to do to make improvements to ensure that people's needs were met. This visit was completed to review the improvements made by the home.

There were 21 people living at the home on the day of our visit and one person was in hospital receiving care. No one knew we would be visiting. We spoke to four care workers and partially looked at four people's care files. We spoke to one person who lived at the home and they told us that they were happy living there. They said 'The staff always make me laugh'.

The majority of the people who live at the home have dementia care needs. Because people with dementia are not always able to tell us about their experiences, we used a formal way to observe people during this visit to help us understand. We call this a Short Observational Framework for Inspection (SOFI). This involved us observing four people for 45 minutes and recording their experiences at regular intervals. This included their state of well being, how they interacted with staff members, other people who live at the home and the environment.

We spent time sitting in the lounge area and observed the care that people received. We saw good interactions between the staff and the people who live at the home and we saw that people were offered choices. People were spoken to in a polite way and people laughed with the staff. During transfers between chairs to wheelchairs, we saw that people's dignity was maintained.

New documentation had been introduced so that staff can monitor people's hygiene needs more easily so that people received regular baths or showers as they chose to.

Some of the people living at the home joined in soft ball activities, with staff and other people who lived at the home. Other people had participated in flower arranging during the morning and some people were showing an interest in soft toys and musical instruments.

Staff spoken to were able to tell us about people's individual care needs and told us what they would do if these needs changed.

Staff told us that they had received training in the Mental Capacity Act and Diabetes care. This should enhance their knowledge and skills.

2 February 2012

During an inspection looking at part of the service

We spoke to three people who live at the home. As the majority of people living at Orchard Manor are unable to communicate we spent several hours in the lounge and dining areas observing the care that people receive.

People told us that there was now more for them to do. We observed that people who were less able or were unable to communicate were not involved in activities. We also observed staff ignoring people and did not always treat people with respect.

We found that care records had been improved and generally identified people's needs, capabilities and choices. However we found that staff were not always fully aware of all people's needs. We found that there was a risk due to poor staff knowledge and practice that people were not always receiving the care that they needed.

We found that people were receiving their medicines safely and as prescribed.

We found that improvements are needed to the management arrangements of the home and ensure that people receive the care that people want and need.

20 July 2011

During a routine inspection

We spoke to five people who live at Orchard manor and five staff.

We saw that people were treated with respect.

We were told that most people have the opportunity to choose what they do and how and where they spend their day. People who have difficulty communicating verbally may not always have appropriate opportunities to express their choices.

People's needs are generally met, although this is not the situation for people whose needs are more complex.

People have their medicines given to them by staff, although improvement is needed to minimise the risk of error.

People told us that staff are helpful and caring. There may not always be sufficient and knowledgeable staff available to understand and meet people's needs.

The home's quality assurance system has not been effective to ensure that people receive the care they need to keep them safe and well.