Orchard Manor Care Home

Updated 2 September 2025

Date of assessment:12 September 2025 to 23 October 2025

The service is a residential and nursing home providing support to older adults living with dementia and physical disabilities. At the time of the assessment, there were 85 people living at the home. The assessment was prompted by information we received about risks to people’s safety, including concerns related to unsafe care practices and governance.

We identified 3 breaches of the legal regulations in relation to person-centred care, safe care and treatment, and good governance. These breaches were based on findings that included inconsistencies and lack of individualisation within care planning, environmental and infection prevention and control risks that had not been effectively mitigated, and governance systems that had not identified or addressed these issues in a timely way. We have asked the provider to submit action plans in response to the concerns found.

The environment was not always clean, well-maintained, or safely organised. We observed several maintenance and environmental issues in several areas of the home, including broken fittings, unsafe flooring, leaks, mould, soiling and unclean bathrooms. Equipment was not always stored safely or kept hygienic, and there were gaps in the completion and/or recording of routine safety checks.

The home environment and décor were not always personalised and did not consistently promote people’s dignity. Some people’s rooms appeared bare, with limited personalisation.

We found inconsistencies within some people’s care planning records. Sections within care plans were sometimes duplicated or unclear, and guidance on when to escalate concerns relating to people’s health was not always specific. Some care plans contained generic wording that did not reflect their individual needs and preferences. Care plans did not always reflect people’s current needs or significant changes in their circumstances.

We observed continence products stored visibly and openly in people’s rooms and communal areas. Some people’s personal toiletries were stored on top of toilets.

Medicines were managed and administered safely in the main. However, protocols for medicines prescribed on a ‘when required’ basis did not always provide clear guidance to staff.

There were enough staff with the right skills, qualifications and experience, and managers ensured staff received appropriate training. However, staff deployment was not always consistent across the home. Staff had received safeguarding training and understood how and when to report concerns. We observed staff were caring and committed in their roles.

Recruitment and induction processes were safe, and staff were supported to develop their skills, with some progressing into senior roles. Staff told us they felt supported to give feedback and were treated fairly.

The leadership team maintained links with external professionals and the local community. Professional partners told us they had confidence in the quality and safety of the provider’s clinical decision-making.

Following our assessment feedback, leaders evidenced learning and made immediate improvements, including to infection prevention and control processes and environmental monitoring. The provider demonstrated an openness and a commitment to improving the quality and safety of the service.

Updated 2 September 2025

We received mixed feedback from people and their relatives. Some people valued the kindness and dedication of staff and told us they were happy with their care. Comments included, “I like it, I like the people,” “I’m being looked after” and “They [staff] are lovely.” Other’s raised concerns about limited engagement, isolation, lack of personal independence, and inconsistent care practices. One person said, “They are not looking after me well. They don’t check on me. I am here on my own.” Another person told us, “I have been left in bed for months. I want to sit up. I don’t have any engagement.”  

Some relatives praised the kindness and professionalism of staff, describing them as “kind” and “hardworking and respectful.” One relative said, “The carers seem, without exception, to be very kind and attentive.” Other comments included, “From day one the home has been excellent. They care, they are professional, and nothing is too much trouble” and “Fantastic. 100%. Everything we have requested or asked for has been carried out.” 

One relative commented, “It [Orchard Manor] needs a little bit of TLC and love and time put into the residents. The staff work so hard and are pulled from pillar to post. You can see the strain on them.” 

Some relatives told us the standard of their loved one’s personal care was poor. Some expressed concerns about delays in support, staffing levels, dignity and the quality of engagement for people who were cared for in bed. One relative said, “We had to ask for [Name] to be positioned to look at the television, not the wall.” Several relatives told us people were not supported to make their own choices or engage in activities. One relative said they were concerned their family member was, “Not getting the care they need.” Some relatives raised concerns about continence care and concerns about the attitude of some members of staff. Concerns were raised about practical issues such as missing possessions, unclear visiting arrangements, and delays in communication. One relative reported, “[Name]’s items went missing and were found being used by other residents.” Some relatives mentioned concerns about activity provision. One relative said, “They [activities] only seem to be on one side of the home. Activities are often cancelled as they have not got enough staff.” 

Some people could not directly tell us about their experience. For people who were unable to communicate with us verbally, we used the Short Observational Framework Inspection (SOFI). SOFI is a structured observation tool designed to help inspectors understand the experiences of people who may not be able to express themselves verbally, often due to conditions such as dementia. We carried out a SOFI on Maple unit and a SOFI on Willow unit. Our observations found staff interactions with people were warm, attentive and engaging on Willow unit. People were enjoying activities and social connection.   However, on Maple unit, it demonstrated staff were making decisions rather than listening to people’s preferences which did not reflect person-centred care