Orchardown Rest Home

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• 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

People were not always safe and protected from avoidable harm. Some staff were trained to recognise abuse in all forms and knew the steps to take if they saw something of concern. Policies and procedures were in place to support staff with managing safeguarding; however, these were not always followed as incidents had not been appropriately reported which meant people could be at risk of harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Safeguarding and whistleblowing policies were in place. The registered manager was aware of their responsibilities on discovering or being informed of a safeguarding incident. However, they had not always reported concerns to CQC and the local authority. Staff told us they were confident to use the whistleblowing policy if needed. Whistleblowing is a process that allows staff to raise concerns about the service whilst protecting their anonymity.

People and their relatives said they were safe and were protected from avoidable harm. People told us they felt safe living at the service. People and relatives told us they were confident to raise issues and concerns and they knew that any matters raised would be resolved in a timely way. A relative said, “I could talk to the manager if I needed.” Throughout our visit we observed good interactions between staff and people with staff talking with and reassuring people. It was clear people enjoyed the company of the staff and felt safe. Although people and relatives gave positive feedback, we observed that people were not always protected from avoidable harm because appropriate actions had not always been taken when required. This was an area for improvement.

Some staff had received training in safeguarding and received regular refresher training. Staff were able to identify the different forms of abuse and circumstances that amount to a safeguarding. Staff were able to tell us the steps they would take on suspecting abuse. Staff were clear about who else to report safeguarding issues to such as notifying the local authority and the Care Quality Commission. A staff member said, “I would report safeguarding to [deputy manager, registered manager] or the owner and I would reassure the resident. If there was abuse it would definitely be reported appropriately. I could report it to the CQC or safeguarding.” The registered manager told us that they were aware of their responsibilities to take action when incidents had occured. However, they had not taken actions since August 2023, as they had been diverted away from the management role to cover other care responsibilities.

Staff were attentive to people and were available to provide support when needed. We observed staff interactions with people and observed care and support in communal areas. Most people were able to mobilise around the home independently. However, some people required walking aids and were more susceptible to falls. Relatives told us that where their loved ones had fallen, they had been kept informed and relevant actions had been taken such as gaining medical help from the GP and gaining equipment. We observed staff being on hand and available to support people as needed. Staff intervened quickly when people were showing signs of anxiety and distress. For example, one person had become agitated and was removing decorations from the tree. Staff intervened, provided support and distraction and the person became more relaxed.

Staff knew people well. They knew about specific risks to people for example, some people had fallen and may be more susceptible to falls. Care plans and risk assessments were reviewed monthly. One person’s care plan stated they had not fallen in 12 months which conflicted with information found in accident and incident records. The registered manager told us they had been overwhelmed with the amount of work because of covering for care staff and other roles in the service which had caused things to slip. Discussions with staff and the registered manager evidenced that staff were completing accident and incident forms when accidents and incidents took place. Immediate actions had taken place, which included contacting relevant health professionals and carrying out checks.

Accidents and incidents had not always identified any learning and had not led to risk assessments being completed when required. This meant that risk was not always being well managed for people. For example, one person experienced a fall whilst they were accessing the community alone which resulted in an injury. Medical help was sourced at the time. However, this had not led to a review and relevant risk assessments being completed and the fall had not been reported to the local authority or CQC. Processes for recording and reporting of accidents and incidents had been more robust up until July and August 2023. No analysis had been completed since this date. Personal Emergency Evacuation Plans (PEEPs) were not up to date. One person’s mobility had declined substantially which meant they were no longer able to walk. Their PEEP did not identify what support they needed from staff (including what equipment they would need) to safely evacuate the home in an emergency. There was no equipment in place to support them. We discussed this with the registered manager, who took action to update the PEEP and order equipment to keep people safe. Testing of fire and other equipment was recorded and there were weekly fire alarm tests and mock drills up until August 2023. Registered persons had failed to protect people from risks to their safety. Accidents and incidents had not always been responded to and reviewed. This placed people at risk. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Risks to people were not always documented and well managed. We observed one person’s needs had substantially changed, however risks had not been reviewed and updated to ensure that staff had all the information they needed to work with the person safely. People told us they felt supported by staff who knew them well and were aware of their medical, health and social needs. People were encouraged and supported to be independent with daily tasks and activities but without compromising their safety.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff were recruited safely. We looked at 3 staff files and each contained the required documents confirming safe recruitment. Documents included application forms, photographic identification, references and in date copies of Disclosure and Barring Service forms (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Staff training was up not always up to date. Some newer staff had not completed mandatory training and a number of staff required refresher training. Training in some areas had been scheduled across 2024. Most staff were supported by managers with regular supervision meetings and staff meetings. The management team did not have a full understanding of staff members training needs as some staff received training from other employers. Registered persons had not ensured that they had received training relevant to their current role.

The registered manager told us there were some vacancies in the staffing team which meant they and the deputy manager were deployed to provide care and other tasks such as cooking. The registered manager recognised this took them away from their management positions, which had impacted on their ability to monitor the service and make improvements. Agency staff were not used to backfill vacant positions. A member of staff told us, “Personally I don’t think there are enough staff on at night to safely evacuate people, there’s enough staff during the day.” New staff completed an induction. Staff told us they had regular training, supervision and support. Staff told us they had opportunities to raise issues or concerns with the management team or provider and that they were confident issues raised would be dealt with. The registered manager told us that staff received medicines competency checks which were undertaken by the deputy manager. Staff had not received formal checks to make sure they were competent using moving and handling equipment to move people safely. The registered manager told us they would ensure these checks were put in place.

Feedback received from people and their relatives confirmed that there were enough staff at the home. However, our assessment evidenced there were not enough staff deployed on shift at night to safely manage people’s needs should an emergency occur. We reported this to the registered manager, who took immediate action to increase the staffing levels. Comments from people included, “Girls [staff] are friendly, I am happy to talk to them if I needed anything, they are very caring”; “That’s a funny question and difficult to answer [in response to if there was enough staff]. They do come and help us if we need them to.” A relative said, “There’s enough staff, they are always busy but there is enough of them.” Another relative told us, “99% of the time there is enough staff.”

During the day there were 2 carers on duty, the registered manager and deputy manager and specialist staff for example, kitchen and domestic staff. The staff rota showed there was 1 staff member on duty at night, which would not be sufficient to meet people's needs. We observed call bells were answered quickly. Peoples needs had changed; staffing levels had not been reviewed, reassessed or amended which had led to the management team providing support to care staff on duty during the day in order to meet people’s needs.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.