10 June 2022
During an inspection looking at part of the service
Orchard Cottage is a residential care home providing personal to up to 10 people. The service provides support to older people who had varying care needs including, dementia, diabetes and mental health needs. At the time of our inspection there were 10 people using the service.
People’s experience of using this service and what we found
Individual risks were not effectively identified and managed to keep people safe. Lessons were not learnt from accidents and incidents to prevent future occurrences. People were not always protected from the risk of abuse as staff did not have a good knowledge of what action to take. Peoples medicines were not managed well or in a safe way. There were not sufficient staff on duty to effectively meet people’s needs and keep them safe.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
People did not have a full assessment of their needs in order to develop care plans that were individual and reflected their health and care needs. People did not always have access to advice and treatment from the appropriate healthcare professional. The environment was not suitable for some people living at Orchard Cottage, such as people living with dementia.
Staff training was insufficient to meet staff needs. There were gaps in staff skills and knowledge which meant people did not always receive the help they needed.
The provider and registered manager did not have sufficient oversight of the service. Records did not reflect the changing needs of people. There was no process to monitor the quality and safety of the care provided to people to identify areas for improvement or take action when needed.
People received sufficient food and snacks and had a choice. People could request certain meals and their requests were acted upon.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 5 May 2022).
Why we inspected
We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted due to concerns received about fire risks, staffing, response to incidents and access to healthcare. A decision was made for us to inspect and examine those risks.
We inspected and found there was a concern with the assessment of individual risk and care needs, staff understanding of the Mental Capacity Act and the management and oversight of the service. We widened the scope of the inspection to become a focused inspection which included the key questions of safe, effective and well-led.
The overall rating for the service has changed from good to inadequate based on the findings of this inspection.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to safe care and treatment, medicines management, capacity and consent and monitoring and oversight of quality and safety at this inspection.
Please see the enforcement action at the end of this report.
Follow up
The provider told us during the inspection the service was no longer financially viable and made the decision to close the service. They worked with the local authority to find suitable alternative accommodation for all the people who were living at Orchard Cottage at the time of the inspection.