Orchard House Care Centre

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people’s needs were not always met.

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

Care planning did not consistently support personalised and responsive care. Person-centred care planning was inconsistent, and information was not always clear, detailed, or up to date to guide staff practice.

This service scored 50 (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 ensure people were at the centre of their care and treatment choices, and staff did not always work in partnership with people to respond to changes in their needs.

Care records contained elements of person-centred planning, but implementation of this was inconsistent. Staff knowledge and practice were not always aligned with individual needs, risks, or preferences. Some care plans focused on reactive support rather than proactive strategies, and positive behavioural support approaches were not consistently applied for people experiencing distress or agitation.

We saw some staff responses escalated the distress of people with dementia, despite distress support plans being in place. For example, 1 person assessed as being at very high risk of falls had a generic moving and handling risk assessment that did not specify wheelchair use or the number of staff required for transfers. We observed staff support the person in a way that was not aligned with care plan guidance, which increased the person’s distress.

One person had written “HELP” on their bedroom wall and told us, “I am a prisoner in my own room,” and “I am frightened of the man coming in at night.” Staff were unaware of the reasons for the person’s distress, and a support plan was only completed after the inspection.

However, we observed some positive interactions. Staff sometimes engaged effectively with people using their preferred communication methods, and some staff demonstrated knowledge of individuals’ backgrounds and preferences. One person said, “I have made friends with the staff, and they all know me very well,” and a relative added, “Staff try and offer personalised care and they know [person] well.”

The provider did not always demonstrate a clear understanding of the diverse health and care needs of people using the service. As a result, care was not consistently joined-up, flexible, or supportive of choice and continuity. While staffing rotas supported some consistency of allocation, variability in staff knowledge of individuals and incomplete communication of significant events limited assurance that care was consistently informed and person-centred.

Staff knowledge of people’s needs and circumstances was inconsistent. For example, we asked 3 different staff members for a person’s name, but they were unable to identify a person who had been admitted 2 weeks prior. Communication barriers also affected continuity of care. Some staff on duty had limited English language proficiency, which created challenges in communicating with colleagues and people using the service. Gender preferences and culturally specific needs were not always considered when allocating staff to provide care.

Relatives also highlighted concerns about staff understanding of people’s culture and religion, which sometimes made engagement difficult. Staff told us they sometimes found it challenging to support people when they first arrived at the service, particularly when staffing levels were stretched. One staff member said, “It can be upsetting when a person living with dementia has come in and they are unsettled and in a new home (…) We don’t get enough time to settle them in properly. It must be quite scary for them to be in an unknown place.” Another staff member said, “We have a lot of staff who do not speak good English. At least I cannot understand them, let alone our residents.” This meant people’s cultural, religious, and individual needs were not always understood or supported, leaving them at risk of feeling unsettled, anxious, or isolated.

The provider did not always ensure people and their representatives were fully informed about significant changes affecting care or wellbeing.

Confidentiality and timely communication were not consistently maintained in practice. During inspection, we observed a staff station left unattended with a computer unlocked, displaying confidential personal information on 2 occasions. These incidents created a risk of unauthorised access and did not meet data protection standards.

Relatives told us the service had not consistently communicated incidents or hospital admissions promptly. Three relatives reported they were not informed when people were unwell or admitted to hospital, limiting their ability to support decision-making. This meant people and their representatives were not always fully informed about changes affecting care or wellbeing.

However, the provider had systems in place to share information and demonstrated awareness of accessible communication standards. Service user guides and newsletters provided updates about activities, events, and service initiatives. Staff adapted communication using pictorial aids, signs, and body language to support people with language or cognitive barriers. Staff generally supported individuals effectively where people had additional communication needs, and information was available in a range of accessible formats.

The provider did not always make it easy for people to share feedback, raise complaints, or be fully involved in decisions about their care, treatment, and support.

Three relatives told us they felt dismissed by the registered manager or that their concerns had not been handled appropriately. Some complaints had not been recorded in the provider’s complaints log, meaning we could not be assured these concerns had been investigated or resolved. Staff also reported that feedback raised through internal surveys or formal channels did not always lead to sustained improvements or visible accountability, which affected morale and confidence in leadership.

People told us they were able to raise concerns, and some relatives reported that issues had been addressed in a timely manner. This meant that, while people generally felt able to share feedback, inconsistencies in how concerns were managed reduced confidence that all issues were followed up and resolved.

However, the provider had formal systems to gather feedback and respond to survey outcomes. Annual surveys were carried out, with the most recent survey reporting largely positive responses. Feedback and service improvements were communicated using a ‘You Said, We Did’ approach.

The provider did not always ensure people could access the care, support, and treatment they needed in a timely and equitable way.

Follow-up on health or comfort concerns was not consistently timely. For example, 1 person told us their dentures were very painful. The concern was raised with management on the 3 February 2026, during the inspection. Records reviewed on the 9 February 2026 showed no action had been taken since the feedback had been given. This meant the person’s health and comfort needs were not addressed promptly, placing them at risk of pain, distress, and reduced wellbeing.

Some people experienced difficulties accessing preferred personal care, such as showers. One person said, “I have a wash in the morning. The shower has no seat, but I would like showers again.” This demonstrated that equipment and resources were not always sufficient to meet individual needs, limiting people’s equitable access to care and support.

However, people were supported to attend a range of healthcare and community services, including hospital appointments, podiatry, and hairdressing. Emergency protocols and an on-call system were in place to manage urgent concerns. Service user guides provided information about available services and links with the local community. Relatives confirmed that transport and staff support were usually arranged when people needed to attend appointments.

Staff and leaders did not consistently use information about people who may be at risk of experiencing inequality in their care, experiences, or outcomes. As a result, care and support were not always tailored to individual needs, and some people faced barriers to accessing activities, healthcare, and community opportunities.

We found people with sensory impairments, cognitive impairment, communication needs, mobility restrictions, higher support needs, or specific gender preferences did not always have the same access to care support, healthcare, engagement, or choice as others. This meant they were not being supported to maintain their health, identity, and quality of life as those at less risk of experiencing inequalities.

Access to the community and social activity was also inequitable. For example, 1 person told us they could not attend church on Sundays because wheelchair transport was not always available. Although the service had a minibus, not all staff were authorised to drive it, reducing reliable access to community activities. Activities were mostly delivered in communal areas, with limited provision for people care for in bed bed or living in the ‘Memory Lane Unit’. Activity records for several people with dementia showed gaps of up to 7 days without recorded engagement. This showed the impact of staffing and resource limitations on equitable participation.

Feedback from people and relatives was mixed. Some reported feeling included in activities and daily life, while others described barriers related to mobility, staffing levels, or transport availability.

People were not always supported to plan for significant life changes, including end-of-life care. This limited their ability to make informed decisions about future care and reduced assurance that their wishes would be consistently understood and respected.

Advance care planning records were often generic and did not consistently provider clear, person-centred guidance for staff about people’s values, priorities or wishes for end-of-life care. Care plans documented Do Not Attempt Resuscitation (DNAR) status and preferences regarding hospital admission, but they frequently lacked detail on individual end-of-life wishes or how people wanted to be supported as their health declined.

However, where advance planning discussions had taken place, staff demonstrated awareness of people’s preferences, and some documentation reflected wishes for future care and end-of-life arrangements. This meant that while some planning for the future was in place, inconsistencies in recording and involvement of people and their representatives reduced assurance that care would consistently meet people’s long-term preferences and needs.