Orchard Manor Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk people could be harmed. The provider was in breach of the regulation related to safe care and treatment. Care plans contained contradictory or vague instructions and escalation thresholds were unclear. Environmental hazards and poor infection control practices compromised safety.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider took steps to promote a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported concerns. However, lessons were not always learnt to continually identify and embed good practice. Although learning mechanisms were in place, we found they were not always fully embedded and did not consistently lead to timely identification or mitigation of risks, as some improvements made were reactive. Risk assessments and environmental monitoring processes were in place prior to the assessment but were strengthened and expanded following feedback from our assessment. Although environmental walkarounds, maintenance logs, incident reviews and care plan audits were in use, these did not consistently result in timely risk mitigation. At the time of assessment, environmental hazards and hygiene concerns remained present in some areas, and aspects of care planning contained vague or contradictory guidance about escalation and risk management. These issues were addressed and strengthened following inspection feedback, rather than being identified and resolved through the provider’s routine governance and learning systems. This demonstrated that learning from audits and reviews was not always embedded into day-to-day practice in a way that prevented risks from recurring or ensured sustained, proactive improvement. Staff told us there was a supportive and collaborative culture and they felt confident to raise concerns. One staff member said, “Management are approachable and have an open-door policy.” Staff were encouraged to reflect on incidents and complaints and learn from them. For example, following a concern about a person’s hydration, the provider responded by improving visual reminders for staff and implemented checks to ensure hydration care practices were being followed. Leaders told us about ‘Feedback Fridays’ where staff were encouraged to share views, suggest improvements and raise concerns. Professional partners confirmed the provider was proactive in seeking advice. One professional partner said, “Staff have been proactive in seeking specialist advice or raising concerns on behalf of the patients I see.”

The provider did not always work effectively with people to establish and maintain safe systems of care. People’s care plans included important risk information such as choking, aspiration, and pressure injury, but they often lacked clear guidance for staff on how to escalate concerns. For a person whose health condition required close monitoring, their care plan did not specify when staff should escalate to a GP or emergency services. Many care plans shared identical template wording, making it difficult to identify people’s individual needs and risks. Emergency and evacuation planning was not always safe or personalised. Guidance for staff was often generic or contradictory, and documentation did not consistently set out clear levels of support for safe evacuation. Some people’s personal evacuation plans (PEEPs) did not include the mobility aids they needed to safely evacuate in the event of a fire. One person’s PEEP contained conflicting information regarding their mobility and sensory abilities. Another person’s PEEP did not reflect the complex behavioural and mobility needs recorded in their care plan. Some evacuation plans contained incomplete information, with key fields left blank, which reduced our assurance that plans were accurate and fully individualised. We were not assured evacuation plans were accurate for each person or that people would be safely supported in an emergency. Professional partners told us the provider supported continuity of care and best recognised practice. They confirmed staff followed treatment plans, care pathways and specialist advice. One professional partner said,“ Staff are transparent, records are accessible, and we can talk to residents.” Another professional told us,“ The [Provider] generally maintained clear and accessible records.” Leaders described structured handovers between senior care staff, nurses, and night and day teams.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. Staff had completed safeguarding training and were able to explain how they would recognise and escalate concerns about neglect, abuse, or poor practice. Staff told us they felt safeguarding concerns were addressed appropriately by the provider. Comments included, “Any issues raised have been dealt with swiftly and effectively” and “I am well aware of the policies regarding reporting incidents, whistleblowing, and infection control, and can access them anytime.” A professional partner told us incidents were, “Appropriately referred and acted upon.” Comments from relatives included, “I do think they are safe”, “[Name] has had a couple of falls and is mainly nursed in bed but when mobile they did have close observation and the safety equipment” and “Yes, I do think [Name] is safe. They went through a stage of falling and side rails were put on.” Safeguarding incidents were documented and followed up in line with local authority expectations and the CQC were notified of incidents appropriately. 

The provider did not always work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services. People’s care plans included important risk information such as choking, aspiration, and pressure injury, but they often lacked clear guidance to staff on how to escalate concerns. For one person whose health condition required close monitoring, their care plan did not specify when staff should escalate to a GP or emergency services. Many care plans shared identical template wording, making it difficult to identify people’s individual needs and risks. Emergency and evacuation planning was not always safe or personalised. Guidance for staff was often generic or contradictory, leaving staff to interpret safe levels of support. Some people’s personal evacuation plan’s (PEEPs) did not include the mobility aids they needed to safely evacuate in the event of a fire. One person’s PEEP contained conflicting information regarding their mobility and sensory abilities. Another person’s PEEP did not reflect the complex behavioural and mobility needs recorded in their care plan. Important information, including the number of disabled fires exits and wheelchair measurements, were left blank. We were not assured evacuation plans were accurate for each person or people would be safely supported in an emergency. Professional partners told us the provider supported continuity of care and best recognised practice. They confirmed staff follow treatment plans, care pathways, and specialist advice. One professional partner said, “Staff are transparent, records are accessible, and we can talk to residents.” Another professional told us, “The [Provider] generally maintained clear and accessible records.” Leaders described structured handovers between senior care staff, nurses, and night and day teams.

The provider did not always detect or control potential risks in the care environment. They did not make sure equipment, and facilities supported the delivery of safe care. While systems for environmental monitoring and maintenance were in place, these were not effective in identifying, prioritising, and addressing risks in a timely way. We found repeated environmental and safety issues that had not been addressed. There was evidence of poor maintenance and issues with equipment in several areas of the home. We observed multiple hazards within the environment, including broken fittings, exposed nails, trailing wires, unsafe flooring, broken taps, leaks, mould, soiling, unclean bathrooms and communal areas, unsafe food storage, and equipment that was not consistently cleaned. Mattress pressure gauges in some people’s rooms were left on the floor or hanging off beds. Floor sensors were not always switched on, functional, or appropriately positioned. These issues increased the risk of harm and did not provide assurance that people were cared for in a safe environment. Some relatives told us they felt the environment was safe. One relative said, “Although the home is very basic and clinical, it is always kept clear of hazards.” Other relatives told us they had seen the provider respond to hazards and environmental issues following CQC’s visit. One person said, “I have seen improvements since CQC came in. Decoration has improved and [Name]’s catheter bag now on a stand.”

The provider did not always effectively deploy staff so that people received the care they needed, when they needed it. The staffing dependency tool used by managers was suitable for its purpose because it helped to understand which roles were needed. However, we found deployment of staff and engagement with people varied across the home. People and their relatives told us there were not always enough staff available during busy periods or when multiple people needed support with moving around and nutrition. One person told us, “They haven’t got enough time to care for you.” Some people were left without drinks, stimulation and support. One relative said, “They need more staff in the lounge, especially when it comes to changing. I saw there were 8 residents and only 1 member of staff who was sat at the table documenting. If someone had stood up no one was there. No one was interacting with residents.” Another relative commented, “There are lots of changes. I know 4 [members of staff] well. Sometimes it’s just agency.” There were long-standing members of staff within the team, and several had been promoted into senior roles. There was a safe and structured recruitment and induction process, including supervised induction shifts and ongoing competency assessments. Leaders told us agency staff undergo a three-day induction, and a buddy system was in place to provide them with support and guidance. The registered manager said they monitor competence before allowing staff to work independently. One staff member said, “The training is very thorough, mostly e-learning with some practical sessions such as fire drills and manual handling." Staff described morale as positive. One staff member said,“ We are like a family who look out for each other.”

The provider did not always assess or manage the risk of infection. Infection prevention and control systems were in place, however, these were not implemented or monitored effectively, and this meant risks of infection were not adequately assessed or managed at the time of the assessment. The provider did not always detect or control the risk of infection spreading. There was evidence of poor cleanliness in several areas of the home, including dust, cobwebs, mould, evidence of soiled materials and contaminated items were stored alongside personal care products in some communal bathrooms. Staff areas and a kitchenette were unclean. Cleaning audits were incomplete for some areas. Some people’s rooms contained soiled furniture, rusted fittings, and damaged flooring. We found dried and fresh bodily fluids and food waste under pressure cushions, and under and on chair cushions. This created infection risks and did not provide a safe, comfortable living space. Some relatives told us there were cleanliness issues. Comments included, “There is a care home smell. I wipe down [Name]’s table as the tables are often dirty. I clean round [Name]’s room. They don’t wash tables after eating or wash residents’ hands” and“ Willow kitchen is not very hygienic at all.” One relative said, “It [cleanliness] has improved in the last week [since CQC visited].” Some relatives raised infection control concerns about a recent COVID-19 outbreak. They reported that when they visited, there was no visible signage or communication to inform them. One relative said, "It was concerning not to be told as some relatives are vulnerable.” Other relatives told us the environment was kept clean. Comments included,“[Name]’s room is always clean” and “It is clean. It doesn’t smell.” The main kitchen maintained good food hygiene standards, and the laundry room was kept clean and organised. New equipment had recently been purchased for the laundry room.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involvement of people and their relatives in planning was not always consistently evidenced within medicines-related documentation. We found guidance for giving ‘as needed’ (PRN) medicines wasn’t always clear and did not always provide the information needed to give these medicines safely. Instructions were not always complete within people’s care plans, including maximum doses, times between doses, and what actions to take if a person’s symptoms did not improve. For example, a person’s care plan gave conflicting instructions about several PRN medicines, including different maximum doses and timings. Staff were advised to give medicines ‘if in pain’ or ‘if agitated’, but person-specific thresholds, monitoring guidance and escalation instructions were not consistently clear or complete within PRN documentation. Monitoring tools and person-specific information were available for some people, including within behaviour support planning and clinical monitoring systems; however, PRN guidance did not consistently reference or integrate these. For example, staff were advised to give morphine ‘if in pain’ but there was no clear guidance within the PRN protocol on when to contact a medical professional or how to review effectiveness at the point of administration. Leaders told us GP ward rounds took place which provided opportunities for review. However, this did not remove the need for clear PRN guidance and escalation instructions at the point of administration. Homely remedies were to be used for some people ‘as needed’ but review guidance was not consistently clear within records, which increased the risk of delay in medical review. Staff who administered medicines demonstrated an awareness of safe practice. They were aware of medication and dietary interactions. Systems were in place to ensure medicines were ordered, stored, and handled appropriately and securely.