Orchard House Care Centre

Updated 15 January 2026

Date of Assessment: 2 February to 4 February 2026.

The assessment was prompted by concerns raised regarding people’s care and support, risk management, escalation of health deterioration, leadership and staff culture.

We found that the provider was in breach of the regulations relating to person centred care, dignity and respect, consent, safe care and treatment, safeguarding, good governance and staffing. The provider was no longer in breach of regulation in relation to fit and proper persons employed. We discussed the concerns found during our inspection with the management team and we raised concerns to the local authority.

Care was not consistently tailored to individuals’ needs, preferences, or risks. Care plans were incomplete or not followed in practice. Staff did not consistently apply an appropriate approach to support people’s frustration, anxiety or confusion, and interactions sometimes escalated distress in people living with dementia.

People’s dignity and comfort were not always maintained, and staff did not consistently respect people’s rights to make decisions about their care. Environmental risks, infection prevention controls, medicines management, nutrition, hydration, and skin integrity practices were inconsistent, increasing the risk of harm. Clinical observations were delayed or missed, and care interventions did not reliably mitigate identified risks.

Staff did not always respond promptly to people’s immediate needs or escalate safeguarding concerns appropriately. Call bells were sometimes out of reach, and people living with cognitive impairment were observed unsupervised or in unsafe conditions, placing them at risk of harm.

Staffing levels, skill mix, supervision, and support were inconsistent, limiting staff capacity to deliver safe and person-centred care. Workforce wellbeing was not consistently promoted.

Oversight, audits, and quality assurance systems were ineffective. Repeated gaps in care planning, risk management, staffing, and personal care had not been addressed since previous inspections. Communication between staff was fragmented, and serious incidents were not consistently reviewed or used to improve practice.

We have asked the provider for an action plan in response to the concerns identified at this assessment relating to person-centred care, dignity and respect, consent to care and treatment, and staffing.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

Updated 15 January 2026

People and relatives reported a mix of positive and concerning experiences of the service. Some people said, “Staff are compassionate and trusting,” “Staff are all lovely,” “The food is very good,” and “Staff are nice to me and care is very good.” Relatives also described positive aspects, noting, “Staff are very supportive and helpful,” “[Person] is looked after,” and “[Person] always looks clean and tidy, as does the home.” These comments show that some staff were able to provide attentive, kind, and reassuring care.

Some people were not able to tell us about their experiences of care and inspection findings highlighted significant inconsistencies in people’s day-to-day experiences. People did not always receive timely responses to call bells. We observed support with nutrition and hydration was variable, and opportunities for meaningful engagement or activity were limited. Those with dementia were particularly affected. We observed people exposed to undignified treatment and unmet personal care needs. Care plans were not consistently accurate, up to date, or followed by staff, which affected people’s choice, independence, and dignity.

Staff did not always obtain consent, respect preferences or individual needs. This included cultural, religious, or gender-specific considerations. While some staff demonstrated empathy and person-centred practice, others failed to respond appropriately to distress or changes in people’s condition, leaving individuals at risk of increased discomfort or harm.

While positive experiences were evident in parts of the service, inconsistent care, limited engagement, and variable responsiveness meant that people’s care needs were not consistently met.