Orchard House

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 changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment, assessing the risk of, and preventing, detecting and controlling the spread of, infections, and staffing.

This service scored 31 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice. There were systems in place to share learning and hold debriefs with staff after an incident, though we could not always see evidence of them taking place. On the day we visited there was a regular staff meeting discussing the learning from a recent incident, and how staff should monitor an individual who was at risk of urinary tract infections. However, learning systems had not identified that risks to some people particularly around constipation and epilepsy were not being safely managed, and were exposing people to harm. Incident investigations lacked detail, for example we identified an incident where one person had been hitting their head against a wall but there was no documentation as to whether staff had sought medical advice or cushioned this person’s head to ensure their safety. The investigation report had not identified this or taken appropriate learning.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. All the people living at the service when we visited had done so for a number of years. Relatives we spoke to commented that they felt their relatives received continuity of care. One relative stated “I feel staff understand and communicate with (person) well, and they benefit from a consistent staff team working with them”. Though people gave positive feedback, we observed that the provider had not always monitored the safety of the people living at the service, or proactively sought advice from partners to respond to people’s changing needs. We observed staff supporting one person to be raised from their wheelchair using a belt, in a manner that their risk assessment has explicitly stated they should not do because it was unsafe and could result in harm. The risk assessment stated this person could stand independently but we observed this was not the case however, the provider had not sought updated guidance from health professionals or updated the risk assessment to describe how they could safely support this person. The provider had not identified that the way care was being delivered in practice was not always reflective of the care planning or risk assessments in place.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and abuse. Though we observed staff had undertaken safeguarding training, they were not always knowledgeable about their responsibilities when they were concerned abuse or neglect might be taking place. Though they explained they would report this to management, they weren’t always aware of how to make a safeguarding referral to social services. Staff were not always knowledgeable about how to support people safely in line with risk assessments. Where restrictions had been put in place on people, there was not always documented to show how the provider had assessed this was in a person’s best interest. Where these decisions had been made, we could not be assured that people’s families or representatives had been involved to advocate for people.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. The majority of people living at the service had a risk of constipation, but there were not always risk assessments in place for how staff could support people to safely manage this. Where they were in place, they were not always followed and staff did not have a good knowledge about when they may need to seek medical guidance or how to prevent constipation. Staff were required to contact the GP for people who had not had a bowel movement for 2 days, however we saw one person had recently gone double this time which had not been responded to or recognised by staff. Constipation is a higher risk for individuals with a learning disability or who are autistic due to a reduced ability to communicate or recognise they may be constipated, but the service had not managed this risk effectively.

For those with epilepsy who may require rescue medicine in event of a seizure, staff were not always aware when they would need to administer this. The guidance was for the medicine to be administered after a seizure lasting 3 minutes, but staff stated they may wait as long as 10-15 minutes putting people in danger of severe harm. We were informed by some staff they had not been trained to administer rescue medicine, yet were supporting people into the community on their own meaning we could not be assured people would receive this medicine at all in certain circumstances if required.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. We observed there were audits in place to review the environment and equipment used by people was safe, and found that this was the case in most areas. However, though the poor condition of the kitchen had been identified for over 12 months, the provider had not responded appropriately meaning food was being prepared in an unsafe environment that could not be appropriately cleaned.

The provider did not make sure staff were suitably qualified, skilled and experienced to provide safe care that met people’s individual needs. We identified that on a number of occasions, staff had started into role without DBS (Disclosure and Barring Service) or identification checks to ensure they were a fit and proper individual to work with people. Whilst we observed that there were sufficient numbers of staff, they were not always suitably trained or knowledgeable about the risks to the people they supported. A significant number of people at the service were at risk of constipation and their risk assessments stated that staff would receive training around continence, however this was not in place and staff did not have a detailed knowledge of how they would respond to constipation. Records we saw stated that staff had received training in epilepsy and use of rescue medication, but despite this some staff stated they had not and could not describe how they would administer this if needed. Staff also did not have a consistent knowledge of how to ensure people were consenting to care. The service had not identified these gaps in knowledge.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Though the service was largely clean, the kitchen was in a poor state of repair with degraded surfaces that could not be easily cleaned. This meant we could not be assured that food could be prepared in a clean or safe environment. Though there were plans for a replacement kitchen to be installed during the month following our visit, we observed the provider had known the kitchen was in this condition for period of more than 12 months without appropriate action being taken. We saw an example of washing being dried in a bathroom which also posed a higher infection risk. However staff had received appropriate training in infection prevention, and explained how they would follow hand hygiene principles and wear protective equipment to prevent infection transmission.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We were told that support workers at the service were not trained to administer medicine and this was the responsibility of senior staff. The service was staffed only by support workers at night, who informed us they would need to phone a member of on call staff if any medicine needed to be administered. We were concerned that this meant where people required “as needed” medicine during the night such as painkillers, they would not receive these in a timely manner. Additionally, there were not always sufficient staff who were trained or knowledgeable to administer medicine for those at risk of seizures. Whilst medicine was being stored and recorded safely, we could not be assured that people would receive it when required and were being exposed to a risk of harm as a result.