Orchid Woodlands Healthcare Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff understood their responsibility to provide safe and effective person-centred care to people, in line with the provider’s vision and values for the service. The provider’s policies, procedures and processes supported their vision and values.

The registered and deputy managers used spot checks, supervision and meetings to make sure staff understood and were demonstrating the necessary values in their interactions with people and relatives.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Overall people, relatives and staff provided positive feedback about both the registered and deputy manager and how the home was run. Comments included, “I know that [name] is the manager. I feel it's managed quite well on a day-to-day basis”, “[Name] is the manager, and [name] is the deputy, both are approachable and will listen” and “Yes, I think the home is well run. It’s like a family here, we all support each other. The managers are accommodating when we make requests.”

Staff said they felt supported and had noted improvements being made. One staff stated, “There are improvements daily. We asked if we could have some chairs for relatives to use, as there weren’t always enough when they visited. The manager ordered 8 new chairs, which arrived quickly.”

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had a diverse workforce. Staff we spoke with told us they felt respected and supported within their roles. Staff meetings were held to ensure staff felt included and involved in the home and how it was being run. From minutes viewed, these previously occurred on an ad-hoc basis, rather than to a fixed schedule, though were now held monthly.

A staff survey had been circulated in September 2025, to capture staff’s views on working at the home and the support they received to carry out their roles. Feedback received was largely positive. An action plan had been created to address any issues raised.

The staff notice board contained a range of useful information for all staff members, including information on well-being, teamwork and external organisations staff could contact, if they required additional support.

The provider had clear responsibilities, roles, systems of accountability to help facilitate good governance. However, whilst audits and quality monitoring had been completed consistently, they had not always been effective in identifying shortfalls.

The provider had an internal audit schedule in place which detailed what areas were to be assessed each month. These included care records, health and safety, infection control, medicines and various aspects of care provision. We reviewed audits for the last 6 months, and aside from the most recent audits completed in September 2025, which had effectively identified a number of issues, we were not assured these had consistently identified all shortfalls in practice. For example, we identified issues with the management of medicines, yet the medicines audits all reported compliance rates of 90% or higher. Care plan audits had not identified the minor discrepancies we noted when reviewing care plans. We also noted the same people’s care plans had been audited within the space of 2 months, instead of different people’s being reviewed every month to ensure everyone’s was checked over the course of 12 months.

The provider employed an external compliance manager, who visited the home once a week and provided additional oversight. They completed provider level audits periodically. Recent issues noted had included ensuring all care plans were reviewed to ensure information was correct.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

We noted a number of examples of partnership working and involving the wider community in the home. They were working with Age UK around the provision of workshops tailored to individuals and completion of group exercises for people focusing on mobility, overall well-being and training to teach the basics of the strength and balance exercises which could be done to prevent falls. The provider had been working with healthcare professionals and organisations, with the aim of providing bespoke training to staff in areas such as oral health, continence and use of thickening powder in people’s drinks.

Monthly visits were completed by a vicar from the local church to perform communion for those who wished to participate. The home had made links with local schools who visited periodically. The home had also made links with a nearby stables, who brought their horses to the home for people to look at. Two of the smaller horses actually came into the home so people could pet them. The home had also been visited by a local alpaca charity, who also brought their animals to the home.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people.

We found the completion of actions and implementation of changes to practice to be variable. Where issues had been identified through provider level audits or system partner monitoring, such as reviews carried out by the local authority quality team, we found these had been addressed timely. However, this was not always the case where issues had been identified internally. For example, weight audits had identified an issue with the way people had been weighed in June 2025. This same issue had been documented in July and August’s audit, which suggested either no action had been taken to address the issue, or any improvement had not been sustained.

Any actions identified through audits or quality monitoring processes, whether this be internal or external, were added to the home’s service improvement plan (SIP). The SIP documented any issues, root causes, actions required, due date, who was responsible and a status section, for documenting updates. The SIP was a live document which was updated as and when any actions had been progressed and/or completed. Overall, we found the SIP was being used effectively, and notwithstanding the issues reported with internally completed actions and audits, we saw a large number of improvements to both the environment and practice had been made over the last 12 months.