Orchard House Care Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

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

Care and support were not consistently effective or delivered in line with legal requirements. Gaps in care planning, record keeping, monitoring of health deterioration and management oversight limited assurance that care was consistently effective, lawful, and based on best available evidence.

This service scored 38 (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 always ensure that people’s care and treatment were effective because health, care, wellbeing, and communication needs were not consistently assessed or reviewed. Systems to update care plans were not always used to ensure information was accurate, complete, and reflective of people’s current needs.

Care plans were reviewed through the ’resident of the day’ system. Records did not always reflect diagnosed health conditions or provide clear instructions for responding to deterioration. For example, 1 person with multiple conditions had no care plan to guide support or escalation of health concerns. Another person with Parkinson’s disease lacked a condition-specific plan, and a person with diabetes did not have documented target blood glucose ranges or escalation protocols. This meant staff did not have had the information required to respond to changes in people’s health, increasing the risk of avoidable harm. However, we found some records included detailed condition-specific guidance

Records also contained conflicting information. One person’s care plan stated they were awaiting a dementia diagnosis, while another section recorded a confirmed diagnosis of mixed dementia. Care records were not always updated following incidents or changes in need, this meant we could not be assured people were supported in line with their current needs.

Relatives were not always involved in care planning. Some relatives reported limited awareness of care plans. One relative told us, “Not seen a care plan yet,” while another said, “There were some inconsistences in [Person’s] care plan, but staff have now corrected it.” Staff also reported challenges using the electronic system. Three staff members said they did not have enough time to read people’s full care plans and relied on the “critical information” page, which was not always up to date. This meant staff could not always be fully informed about people’s assessed needs or planned approaches to care.

The provider did not plan or deliver care and treatment in line with people’s assessed needs or with current legislation and evidence-based guidance. The provider used nationally recognised tools to assess people’s needs, and policies aligned with national guidance. However, assessment findings were not effectively used to inform care planning. This meant people’s nutrition, hydration, and skin integrity needs were not consistently met, increasing the risk of avoidable harm.

Care plans included person-centred information about nutrition and hydration. However, they did not always reflect enhanced monitoring or recording where risks were identified. For example, 1 person assessed at high risk of malnutrition was not supported or monitored effectively. Records showed meals were not fortified, quantities consumed were not documented, and weight monitoring showed a loss of 2.8kg between 4 October 2025 and 1 February 2026. During inspection, the person told us they were thirsty and hungry, and records showed that by 22:40 they had consumed only 470ml of fluid for the day, significantly below the provider’s recommended target of 1,200–1,600ml.

Other people assessed as very high risk of dehydration did not always have care plans detailing fluid monitoring requirements or targets. We observed multiple people had drinks placed out of reach, and fluid intake records for 5 people showed they consistently received less than recommended guidelines for both fluid offered and fluid intake, with no refusals documented. Two people assessed as at high risk of pressure wounds lacked skin integrity care plans to guide staff in preventing pressure damage. A third person assessed as requiring 2-hourly repositioning, due to an existing pressure ulcer, had gaps of up to 6 hours between documented repositioning. These shortfalls exposed people to an increased risk of malnutrition, dehydration and skin breakdown.

Relatives also raised concerns about nutrition and hydration. One relative told us, “[Person] needs food to be cut up. Water is often left on the other side of the room and food not cut up. No jug of water or a cup on Sunday, this is not good enough.” In response to our findings, the provider confirmed they were reviewing care planning, monitoring systems, and staff practice.

The provider did not always ensure that staff teams and external services worked effectively together to support people. Structured systems, including weekly GP rounds, healthcare professional referrals, and input from external healthcare partners, were in place. However, these arrangements were not always sufficient to provide continuity of care or mitigate risks associated with information gaps.

Communication within the service was limited by unit-specific handovers. Staff told us they only received handovers for the unit they were allocated to at the start of their shift, despite staff sometimes working across different units. This meant staff did not always have up-to-date information about people outside their allocated unit.

During inspection, a staff member was unaware of the circumstances of a person’s fall because they were allocated to a different unit on the day. When the person returned from hospital without information about diagnosis, treatment or any follow-up required on their discharge summary, records did not show staff had sought further information from the hospital. For example, daily notes stated the person, “returned from hospital after being given the ‘all clear’”. This meant staff did not always have complete information about people’s health needs or any follow-up care required, which could place people at risk of not receiving appropriate monitoring, treatment or support after a hospital visit.

Documentation supporting clinical and medication care was inconsistent. Emergency hospital admission packs were not always up to date or reflective of people’s needs. For example, 1 person’s medication care plan listed 5 allergies, but their emergency pack included only 2 allergies and did not contain the full medication care plan. This increased the risk of medicines errors and delayed clinical responses in an emergency.

While processes existed to coordinate care with external healthcare professionals, gaps in internal communication and incomplete documentation meant staff teams did not always have the information needed to deliver safe, person-centred care.

People had access to regular professional healthcare visits, including general practitioners, podiatrists, and hairdressers. Some activities were tailored to individual interests, such as themed days, outings, and group chair exercise sessions, which aimed to promote physical activity and overall wellbeing.

People and relatives reported mixed experiences of support to maintain wellbeing and reduce loneliness. One person told us, “I wish there was more to do. I often get bored and lonely up here.”

A relative also told us their loved one often appeared lonely or depressed. However, another relative shared a more positive experience, telling us, “[Person] uses a Zimmer frame now, not the wheelchair. [Person’s] mobility has improved and they are much more mobile.”

Care planning and support did not always fully promote healthier lifestyles or wellbeing. Support with oral hygiene was not consistently recorded in care plans, and records demonstrated some people were not receiving assistance. When individuals declined support, staff did not always revisit the offer or escalate repeated refusals to a manager, limiting opportunities to review and adjust care plans. Three relatives highlighted oral care and encouragement with showers or baths an area of concern.

Although some people were encouraged to make healthier choices regarding diet and physical activity, this was inconsistent.

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure outcomes were consistently positive or that care met both clinical standards and people’s individual expectations. Systems to track clinical and wellbeing indicators were not consistently followed by staff. This meant risks were not always identified or acted upon in a timely manner.

Staff identified some risks to people’s health and wellbeing, but reviews were not consistently carried out. The service used a nationally recognised tool to monitor people when they became unwell (NEWS2), which included clinical observations and guidance on escalation. However, follow-up observations were frequently delayed or missed. For example, 2 people’s records showed clinical observations were not consistently taken twice daily during antibiotic treatment, which was not in line with the provider’s protocol.

During our inspection, a staff member raised concerns during a staff meeting attended by the inspection team that a person appeared sleepier than usual. Despite these concerns, clinical observations were not taken for over 3 hours and were only completed after prompting by the inspection team. When clinical observations were taken, the person’s NEWS2 score indicated staff should complete further observations within 30 minutes. However, this was not done until further prompting by the inspection team. Later, the person’s NEWS2 score indicated staff should complete further observations within 2 hours. However, none were taken until the following morning, when the person was found on the floor after slipping from the armchair where they preferred to sleep. The person sustained a head injury requiring hospital attendance. This meant the person did not receive timely clinical monitoring or appropriate escalation when their condition appeared to deteriorate. Staff did not follow NEWS2 guidance or respond promptly to concerns raised, which placed the person at increased risk of harm.

In another instance, a person calling out in significant distress during an out-of-hours period was not escalated to the person in charge for 15 minutes, despite inspectors prompting staff twice.

Following the inspection, the provider confirmed they were reviewing clinical observation monitoring, escalation processes and staff adherence to NEWS2 guidance. They also implemented additional oversight and enrolled staff in NEWS2 retraining to improve timely recognition and response to changes in people’s health.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.

We observed widespread instances where people’s choice was not respected or were ignored, including for people who had mental capacity to express their wishes, but particularly for people with dementia or who were otherwise less able to communicate or contribute to decisions about their care. For example, 1 person in a communal lounge was seated in an overly reclined tilt-and-tip chair that restricted movement. We observed them repeatedly expressing distress and asking to sit upright. However, staff dismissed the concerns, stating the chair had been risk assessed and was in the person’s best interests due to fall risk. Shortly afterwards, 2 staff moved the person to their bedroom for bed rest without seeking consent, providing explanation, or considering preferences. Daily records showed the person was “content”, which did not reflect of our observations. No Mental Capacity Assessment (MCA), or Best Interest decision (BI) had been completed to justify this restrictive action, demonstrating a failure to uphold the person’s autonomy and dignity.

Mental Capacity Assessments were often incomplete, lacked detail, or assumed a lack of capacity. Records did not consistently show how information was presented to support decision-making, or how the functional test of capacity had been applied. Questions were sometimes answered with simple “yes” or “no” responses without further explanation. Some assessments began with an assumption the person lacked capacity, for example, 1 person’s MCA started with the statement of, “[Person] is unable to manage own medicines,” rather than assessing capacity for that specific decision. Decisions made on people’s behalf, including regular supervision and monitoring, also lacked evidence that MCA principles or best interest decision-making had been followed. This meant people were at risk of having decisions made without proper assessment of capacity, putting their rights and autonomy at risk.

Whilst our observations and records showed gaps in practice, 5 people and 10 relatives reported that staff offered choice and encouraged decision-making. One person told us, “Staff give me choice and encourage me to make my own decisions.”

Following inspection, the provider confirmed plans to review MCA and best interest processes, deliver staff training, and improve documentation standards.