Orchard House Care Centre

On this page

• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people did not always feel well-supported, cared for or treated with dignity and respect.

We found two breaches in regulations in relation to people’s dignity and respect, safe care and treatment.

During the inspection, we observed multiple instances where people’s personal care, comfort, and dignity were not consistently maintained. Staff interactions were sometimes dismissive, lacked empathy, or failed to respond appropriately to people’s immediate concerns.

This service scored 45 (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 consistently treat people with kindness, empathy, or respect for their privacy and dignity. While some people and relatives reported positive experiences, others raised serious concerns about personal care, hygiene, and staff behaviour, indicating inconsistent standards that directly impacted people’s wellbeing.

We observed multiple instances where people’s dignity and comfort were not maintained. For example, 1 person had long, dirty fingernails, and staff left them in a soiled bottom sheet after providing personal care. We saw a staff member mimicking a person’s vocabulary while they were in distress, which showed a lack of empathy. We saw 2 people in bed with their doors open, 1 had their continence aid exposed, and another had removed their bedding and continence aid, leaving them fully exposed. A third person was left in a communal lounge for over 15 minutes in a wheelchair with their trousers down, exposing their genitals and continence aid.

Staff communication and attitudes were sometimes dismissive. One staff member responded to a person calling out in distress by saying, “You’ll only fall down again.” This lacked compassion and reassurance. Relatives also reported concerns, including dirty fingernails and people wearing the same clothes for prolonged periods.

The provider acknowledged the need to improve standards of compassion, empathy, and dignity and confirmed plans to review staff practice, training, and supervision to ensure people are treated respectfully and sensitively.

The provider did not consistently ensure that people were treated as individuals or that care, support, and treatment reflected their personal needs, preferences, and values. Staff did not always consider people’s strengths, abilities, aspirations, culture, or other protected characteristics.

Some areas of the home, particularly the dementia unit, were clinical and lacked dementia-friendly signage, which contributed to disorientation and people becoming lost in corridors. Staffing allocations did not consistently reflect individual preferences. For example, during night shifts, only male staff were deployed despite multiple people requiring female support. This included one person whose care plan explicitly stated female-only care, and others known to become distressed when supported by male staff.

Relatives reported additional inconsistencies relating to personal identity. Some clothing in people’s rooms did not belong to them, and one relative told us, “Due to language barriers [Person]’s religion is not really acknowledged, so it is difficult for [Person] to engage with anyone.” This indicates that the person’s religious needs were not consistently considered or incorporated into their daily support, limiting their ability to fully engage and maintain their personal identity.

However, some bedrooms were personalised, offering familiarity and comfort, and some staff were observed adapting their approach using reminiscence and conversation, which was well-received by people. Following inspection, the provider confirmed plans to review staff allocation and monitor individual preferences.

The provider did not consistently promote people’s independence, and people did not always have choice and control over their care, treatment, or daily routines. People were not always aware of their rights, and opportunities to make decisions or participate in meaningful activities were limited.

Some initiatives were in place to support engagement, but these were inconsistently delivered and did not always reflect individual preferences or needs. During the second day of inspection, we observed extended periods without activity and many people were asleep in their rooms, with no engagement across any unit. One person told us, “If anything there could be more entertainment.”

Individual care preferences were not always followed. For example, 1 person’s catheter care schedule was not adhered to. Their catheter was changed on 26 January 2026, but the next change was incorrectly set at 13 weeks instead of their preferred 10-week interval due to previous bladder adhesions. Another person told us, “If I want to get up to use the commode at night, I’m told to do it in my pad. They won’t let me use commode.” This meant people’s individual care preferences were not consistently respected, which placed them at risk of discomfort, distress, or harm.

The provider’s Life Enrichment framework included external activities, outings, and other engagement opportunities. However, these were inconsistently delivered or recorded. A review of 7 people’s activity records identified gaps of more than 7 days for some individuals without any recorded engagement or meaningful activity, meaning people were at increased risk of isolation.

The provider did not consistently listen to or understand people’s needs, views, and wishes. Staff did not always respond promptly to people’s immediate needs or take timely action to minimise discomfort, concern, or distress.

Monitoring systems, such as call bell audits, were not always effective in ensuring a timely response. Several people had call bells out of reach, and responses took between 2 and 10 minutes. Although records indicated most calls were answered within 2 minutes, audit data highlighted multiple instances where people waited 15 to 20 minutes. One person told us, “I can’t get my bell, they have taken my bell away,” and relatives reported concerns including, “bell not always answered” and “bell not always responded quickly; staff take longer to get to [Person] at the weekend.” This meant people were not able to reliably call for support when they needed it, placing them at risk of unmet care needs, delayed assistance, and distress.

We observed multiple people in need of support or guidance but left without timely staff assistance. One person was anxiously searching for their toiletries in the corridor, another person tried to leave the dementia unit via a closed fire door, and two people calling out in distress were ignored or dismissed by staff. We also observed a person walking down the corridor with soiled trousers without prompt support to meet their hygiene needs. This meant people’s immediate care needs were not consistently met, leaving them at risk of distress, discomfort, or potential harm, and highlighted gaps in monitoring and responsiveness.

However, some staff were observed responding quickly when they recognised people’s cues, and records showed that many call bells were answered promptly, indicating that improvements in consistency could positively impact people’s experience. Following inspection, the provider confirmed plans to review staff skill mix, strengthen supervision, and improve responsiveness.

The provider did not consistently care for or promote the wellbeing of staff, and staff were not always supported or enabled to deliver person-centred care. Formal systems, including supervision, appraisal, health declarations, and structured meetings, were not consistently effective in ensuring staff felt supported, safe, or valued. Inconsistent risk assessments and variable management practices limited staff confidence and morale.

Staff feedback was mixed. Eight reported feeling happy, supported, and valued, 7 reported mixed experiences, and 9 described negative experiences. Positive feedback reflected supportive colleagues and a sense of teamwork. Negative feedback included feeling under pressure, stretched, and unable to provide care beyond basic needs, as well as experiences of feeling unsupported, unheard, and unappreciated. Five staff described instances of behaviours from management including being shouted at or humiliated in public, causing embarrassment, distress, low morale, and reduced job satisfaction.

Risk assessments were not always completed to ensure staff were able to carry out their roles safely. Staff feedback also highlighted reported delays in completing risk assessments for routine tasks, requiring them to chase managers to ensure their safety. The provider confirmed they were reviewing risk assessment processes and wellbeing monitoring to better support staff.