Orchard House Nursing Home

Orchard House provides accommodation and personal support for up to 32 older people, who live with dementia. There were also people who lived with a range of health conditions such as strokes, diabetes, heart complaints, Parkinson’s disease and general mobility problems. At the time of the inspection there were 31 people living at the home. It is a large, detached home with accommodation across three floors and two ground floor wing extensions.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

People’s experience of using this service:

People told us and we observed that they were safe and well cared for and their independence was encouraged and maintained. Comments included, “This is a good place to live, I feel safe” and “The staff are very kind.”

The service had made improvements since our last inspection. This meant people’s outcomes had improved in respect of risk and medicine management. However, whilst the provider had progressed quality assurance systems to review the support and care provided, there was a need to further embed and develop some areas of practice that the existing quality assurance systems had missed. For example, some peoples’ care plan had not been updated to reflect recent changes to their health and continence needs.

There were sufficient staff to meet people’s individual needs and robust recruitment procedures ensured they were suitable for their role. Staff received appropriate training and support to enable them to perform their roles effectively.

Visitors told us, “Staff are really helpful and efficient, look after my relative really well” and “The staff team are wonderful.” There was a happy workplace culture and staff we spoke with provided positive feedback and told us they were proud of the service and enjoyed their work.

There were systems in place to monitor people's safety and promote their health and wellbeing, these included health and social risk assessments and care plans. The provider ensured that when things went wrong, these incidents and accidents were recorded and lessons were learned.

People’s nutritional needs were monitored and reviewed. People had a choice of meals provided and staff knew people’s likes and dislikes. People gave very positive feedback about the food. Comments included, “The food is good,” “Very tasty, good quality” and “Good food.”

Orchard House was clean and well maintained and provided a safe and homely environment.

Staff treated people with respect and kindness at all times and were passionate about providing a quality service that was person centred. People were encouraged to live a fulfilled life with activities of their choosing and were supported to keep in contact with their families. Where required mental capacity assessments had been undertaken, so people could be supported with decision making.

People's care was now more person-centred. The care was designed to ensure people's independence was encouraged and maintained. Staff supported people with their mobility and encouraged them to remain active. End of life care planning and documentation guided staff in providing care at this important stage of people’s lives.

There were positive changes to the management team. Improved audits and checks had been developed that ensured the service was continuously striving to improve. Areas identified as needing improvement during the inspection process were immediately taken forward and action plans developed.

The workplace culture was good and there was a lot of laughter and banter between staff and staff and the people they supported. Staff we spoke with provided positive feedback and told us they were proud of the service and enjoyed their work.

The service met the characteristics for a rating of ‘Good’ in four of the five key questions we inspected, with the well-led question remaining ‘Requires Improvement.’ Therefore, our overall rating for the service after this inspection has improved to "Good".

Rating at last inspection:

At the last inspection the service was rated Requires Improvement (report published 01 May 2018).

Why we inspected:

This was a planned inspection based on the rating at the last inspection. At our last inspection of the service in June 2018 we found breaches in Regulation 12 in relation to safety and Regulation 17 in relation to good governance. This inspection found that the breach of regulations have been met.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner. We will follow up on our recommendations at the next scheduled inspection.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions safe, effective, responsive and well led to at least good. This inspection found that some improvements had been made but we found three breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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. It is registered to provide support to a maximum of 32 people and 30 people were using the service at the time of our inspection. The service is intended for older people, who may be living with a physical disability, sensory impairment or a dementia type illness.

This is the second consecutive time the service has been rated Requires Improvement.

The service did not have a registered manager in place. The registered manager had just resigned from their post in March 2018. 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. A manager had been recruited and had been in post for two weeks working alongside the registered manager. This was their first week as manager.

Whilst people told us that they felt safe we found some shortfalls that could potentially impact on people’s safety and well-being.

There were systems and processes to assess and monitor the quality of the service provided. However, we found that audits were not always effective as they had not identified shortfalls in care records, medicine management, staff supervision and staff training. This had the potential to impact on the safety and well-being of people. This meant there were not sufficient numbers of suitably trained staff to meet peoples’ needs. For example, the service supports people who live with diabetes. Staff had not received training in administration of insulin or had their competency checked by a competent person although staff were administering insulin.

Whilst the provider had arrangements in place for the management of medicines, we found some areas of practice that placed people at risk at of not receiving their medicines safely. Medicines had not been given safely as staff had not followed safe guidance whilst giving medicines. Medicines were given from a tray already potted in to a pot and staff were not using the medication administration records (MAR). There were some people at risk of not receiving their prescribed medicines, as there were a number of staff signature omissions (identified as gaps) in medication administration records (MAR). Staff had not completed the MAR record to state why the medicine had not been given. Staff who gave insulin had not received the necessary training nor been assessed as competent in this task. Risk assessments for peoples’ health had not been reviewed or updated following changes to their care despite people’s needs changing significantly. This meant new staff and agency staff would not have the correct up to date information. Accidents and incident reporting had been completed but there was no management overview or audit of falls and incidents to prevent a reoccurrence. This meant measures to ensure lessons were learnt not in place and preventative measures had not been taken.

The provider assessed people's capacity to make their own decisions if there was a reason to question their capacity. Staff spoken with had an understanding of the Mental Capacity Act. Where possible, they supported people to make their own decisions and sought consent before delivering care and support. Where people's care plans contained restrictions on their liberty, applications for legal authorisation had been sent to the relevant authorities as required by the legislation. Staff supported people to eat and drink enough to maintain their health and referred people to other healthcare professionals when a need was identified. Staff worked with healthcare professionals to ensure people could remain at the home at the end of their life and receive appropriate care and treatment. Staff were caring and kind. They knew people well and this enabled them to support them in a person centred way. People told us that staff were very kind and looked after them well. The atmosphere in the home was warm and friendly and conducive to building and maintaining relationships with others in the home as well as with family and friends.

People's diversity was respected and staff responded to people’s social and emotional needs. People told us their needs were met because they were supported and cared for in accordance with their wishes and choices. People and staff were positive about the culture of the service, staff and relatives felt the staff team were approachable and polite. The staff team worked in partnership with other organisations at a local and national level to make sure they were following current good practice. The provider attended local care meetings to share experiences.

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 this report.

We last inspected Orchard House Residential Care on 15 May 2014 where we found it to be compliant with all areas inspected.

A registered manager was in post. 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 and associated Regulations about how the service is run.

Despite people and their relatives positive comments regarding safety we found some areas requiring improvement. We found specialist pressure relieving equipment for two people, who had been assessed as at risk of skin pressure damage, set incorrectly. Not all risk related to the activation of the fire alarm had been considered. Although most areas related to people’s medicines were managed safely, the administration related to people’s prescribed creams required improvement. We identified minor improvements were required for some staff files in regard to seeking previous employment references. The provider took corrective action to either immediately rectify or establish systems to ensure the above concerns were addressed during the inspection.

The provider took steps during our inspection to address our and care staff concerns regarding shortfalls in staffing numbers during specific times on some days.

The layout of parts of the service did always not positively impact on people. For example access was limited for one person to suitable to showering facilities. The location of the smoking area location had not been considered.

Although staff told us they felt they were well supported by senior staff we found the provider had not established consistent processes to gain feedback and offer development discussions to staff via regular supervision or staff surveys.

There were shortfalls in records related to people’s care documentation. This had been associated with the introduction of a new electronic care planning system which had not been robustly trialled prior to its introduction. During our inspection the provider committed to cancel their contract and return to the original care planning system.

We found, and senior staff told us, the effectiveness of their administration time was hindered by the proximity of the office to busy parts of the home which resulted in them being routinely interrupted.

Staff were knowledgeable in safeguarding and action they should take if they suspected abuse was taking place. It was clear staff had spent considerable time with people, getting to know them, gaining an understanding of their personal history and building rapport with them. People were provided with a choice of healthy food and drink ensuring their nutritional needs were met.

People’s needs had been assessed and care plans developed. Care plans contained risk assessments for a range of daily living needs. For example, nutrition, falls, and diabetes. People received the care they required, and staff members were clear on people’s individual needs. Care was provided with kindness and compassion. Staff members were responsive to people’s changing needs. People’s health was carefully monitored and the provider regularly liaised with a range of healthcare professionals for advice and guidance.

People were provided with opportunities to take part in activities ‘in-house’ and to access the local and wider community. People were supported to take an active role in decision making regarding their own daily routines and the general flow of their home.

The provider had a complaints policy; this was displayed in a communal area. People and their relatives told us they knew how to complain.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The registered manager understood when an application should be made and how to submit one. Where people lacked the mental capacity to make specific decisions the home was guided by the principles of the Mental Capacity Act 2005 (MCA).

Staff had an understanding of the vision and philosophy of the home and they spoke positively about their work and the management. The registered manager undertook regular quality assurance reviews to monitor the standard of the service.

Below is a summary of what we found. The summary describes what people using the service, their visitors and the staff told us, what we observed and the records we looked at. There were 31 people living in the home at the time of our inspection. We spoke with ten people who lived at the home, two relatives who were visiting, manager and deputy manager and six members of staff including the chef and house keeping assistant and four healthcare professionals. We also spoke with a podiatrist who was visiting.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found that the environment was safe, clean and hygienic. Medicines and cleaning equipment were all kept in locked cupboards.

Care plans were kept up-to-date and reviewed regularly. Detailed risk assessments were conducted and the home used a helpful dependency assessment to monitor any changes needed to care and treatment. Incidents and accidents were reported and investigated and appropriate action taken in response.

The CQC monitors the operation of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

The home had systems in place to assess and manage risks and to provide safe and effective care. The staff were appropriately trained and training was refreshed and updated regularly. Staff could also take the opportunities provided to study for additional qualifications and to develop their understanding of caring for people with conditions such as dementia. We also found evidence that staff sought advice, where appropriate, from the GP, social services or from the 'in-reach' support team.

Is the service caring?

One person who lived in the home told us, 'The home is very friendly and everyone is kind and helpful'. One relative we spoke with said, 'I can't fault it'.

We spoke with relatives who said they were able to visit the home at any time and one commented 'Made to feel very welcome'. We saw that the staff were kind and considerate and took time not to rush the people over lunch and when moving about within the home. We observed high levels of respect and people were treated with consideration and dignity. Some were receiving very sensitive end-of-life care.

Is the service responsive?

People's needs were assessed before they moved into the home and detailed care plans and risk assessments were maintained and reviewed regularly. We saw that the home used an electronic care system and that system allowed them to access information quickly and efficiently. We saw that the staff monitored weight, blood pressure, nutrition and hydration, and handover sessions were helpful and informative at the beginning and end of every shift. Call bells were answered according to the home's procedure and people had access to a programme of activities.

People were able to choose dishes from the menu and the chef provided for special diets and additional options as requested. People living in the home also engaged with the manager and staff at regular meetings where they could express their views about all aspects of life at the home. They told us that their feedback was acted upon by the manager.

Is the service well-led?

We saw that people provided written feedback on the service and their feedback was acted upon. We saw copies of the questionnaires completed by the people living in the home and their visitors. We saw that incidents, accidents and complaints were reported and appropriate action was taken to prevent a repetition. The manager conducted a series of internal audits and took action promptly to resolve any issues.

We saw that staff asked people for their consent before they provided care and support, and people decided how and where they spent their time. People told us they were very comfortable living at Orchard House. One person said, "We are quite happy here, we do what we like and the staff are very good."

We examined four care plans. We found they identified people's specific needs and that people and their relatives, if appropriate, were involved in making decisions about the care provided. Staff said they did not really have time to read the care plans, although they demonstrated a good understanding of people needs.

We looked at the policies and procedures for medicine management and how they ensured people were safe.

We saw that the premises were well maintained and appropriate health and safety systems were in place.

We reviewed the home's recruitment procedures and found them to be effective.

Quality monitoring processes were used to assess the services provided by the home. We found that people who used the service, their relatives and staff were involved in discussions about the support provided.

Records viewed were found to be relevant and appropriate.

People told us that they could choose what they wanted to do and how they spent their time. Some also said there were not enough activities. When we looked at the activity programme and newsletter we found that a range of activities were provided on weekdays.

We observed that staff were respectful and caring. We spoke to one care worker who said, "We work together as a team with the residents, to ensure they make choices."

We looked at the care planning system and found that two out of the four care plans we looked at did not reflect all of the persons current care needs. However, the staff were able to demonstrate a good understanding of people's needs and how these were met.

We looked at staff files, training records and spoke with three of the care workers. The training matrix was not up to date. However, the staff we spoke with said they had attended all the training listed on the matrix within the last two years.