Orchard House Care Centre

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 requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

We found three breaches in regulations in relation to safe care and treatment, safeguarding and safe and effective staffing.

Systems to assess, monitor, and manage risk did not always keep people safe. The provider did not consistently identify, assess, or mitigate individual risks, environmental hazards, or infection prevention and control risks. People’s medicines were not always managed safely, and safeguarding incidents were not consistently recorded, investigated and escalated externally. Staff deployment and skill mix were not always sufficient to meet people’s needs.

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 demonstrate a consistently proactive and positive culture of safety based on openness and honesty. Systems to report and review incidents were not consistently used effectively to identify learning or reduce risks.

The service had processes for reporting and reviewing accidents and incidents, such as clinical reviews of recurring falls and wounds. However, these were not used effectively to analyse themes and trends, or document learning to prevent recurrence. For example, 1 person assessed as being at high risk of falls had been readmitted to the service after a fall requiring hospital attendance. Records showed staff had reviewed equipment the person used to support their mobility. However, records had not been updated to reflect changes and continued to instruct staff to use equipment that had been removed. A tilt-and-tip chair currently in use had not been risk assessed. We also observed the person’s sensor mat was misaligned when they were in bed. This meant equipment to alert staff to movement might not operate as intended. This increased the risk of avoidable harm.

Staff understood how to recognise and report accidents and incidents. However, staff told us they did not always receive feedback after submitting incident reports and did not always see timely action taken. Nine staff told us they felt discouraged from raising concerns due to responses from leaders, for example, 1 member of staff told us, “Incidents don’t get investigated properly and a lot of the time its swiped under the carpet”.

The provider told us they had begun reviewing incident management and oversight arrangements and were taking steps to strengthen these processes.

The provider did not always work effectively with people and healthcare partners to maintain safe systems of care. They did not consistently manage or monitor people’s safety or ensure continuity of care when people moved between services.

Systems to support safe admissions and transitions were not used consistently. The service completed pre-admission assessments and had structured guidance for new arrivals. However, records were often generic and lacked personalised information about people’s care and communication needs, behaviours, preferences, and likes or dislikes. Two people had no pre-admission information available. This meant staff did not always have sufficient information to plan or deliver personalised care when people first arrived.

Information sharing between staff during transitions from other services was inconsistent. We observed a mid-morning head of department meeting where discussions about a new admission did not include key details such as mobility, continence, nutrition, or personal care needs. Staff told us they sometimes received limited information about people’s health needs on arrival. One staff member told us, “We eventually found out this person had bowel cancer but only a few weeks after they arrived.” This meant staff did not always have information to respond promptly to health needs.

Feedback from external professionals also highlighted shortfalls in robust assessment of people’s needs and therefore in continuity of care. One healthcare professional told us, “The home has served notice on a service user shortly after an emergency admission”.

However, people and relatives described some positive experiences of transitions. One relative told us, “Orchard House took us all into their caring arms and have supported us with kindness and forethought through what has proved to be a very daunting, emotional rollercoaster journey.” This showed that while information sharing was inconsistent, people and families generally experienced supportive care during transitions.

The provider did not work effectively with people or healthcare partners to understand what being safe meant to them or how to achieve it. They did not consistently protect people’s right to live safely, free from bullying, harassment, abuse, discrimination, avoidable harm, or neglect. Concerns were not always shared quickly or appropriately, which left people exposed to risk of harm.

The provider had safeguarding systems, including a safeguarding policy, safeguarding training for staff, and a safeguarding log and tracker to record referrals and outcomes. However, staff did not consistently follow these processes. A person who experienced physical abuse in August 2025, when another person entered their room. They later sustained an unexplained injury to their back, on 27 January 2026. Staff did not escalate this injury to the local authority as a safeguarding concern, despite the person’s known vulnerability and unknown origin of the injury. During our inspection, we observed people entering this person’s room without supervision. This meant we could not be assured measures were implemented to ensure the person was protected from the known risk of harm.

Safeguarding responses were not always effective when incidents occurred. We observed 1 person entered another person’s bedroom while they were asleep. Staff physically removed the individual, who resisted, and 10 minutes later, records show staff recorded the person sustained bruising to their hand. Staff recorded the injury as “unknown” on the accident and incident form, and internal records contained inconsistencies in the timing and description of the incident. This meant we could not be assured incidents would be accurately reported to ensure people were protected from improper treatment.

Staffing allocations did not reflect known risks in care records, including ensuring appropriate staffing mix to avoid distress triggered for specific people by male staff. Staff also told us safeguarding concerns were not always escalated appropriately. Three staff members told us of incidents of alleged abuse they had reported, but records showed managers had not recorded these on the safeguarding tracker or reported them to the local authority.

Following inspection, we raised these concerns with the local authority safeguarding team. The provider had begun investigating these incidents and was reviewing safeguarding processes and record keeping to improve oversight, accurate documentation, and timely escalation of safeguarding concerns.

The provider did not work effectively with people to understand and manage risks. Staff did not consistently provide care that was safe, supportive, or enabled people to do the things that mattered to them. Although systems for risk assessment existed, they were not always detailed or reflective of individual needs, which meant risks were not consistently identified or mitigated.

Risk assessments were not always personalised or reflective of people’s behaviours and needs. The service used structured risk assessment tools and reviewed these alongside care plans through the provider’s ’resident of the day’ process. However, records were often generic and did not describe known behaviours that increased risks. For example, we observed that 1 person with bed rails, who had removed the bed bumpers and positioned their legs over the rails. However, their bed rails risk assessment did not describe this known behaviour or assess the increased risk of entrapment or injury. This meant staff did not have clear guidance on how to reduce the risk and exposed the person to the risk of avoidable harm”.

Health-related risk management plans were incomplete or absent. A person diagnosed with epilepsy did not have an epilepsy care plan or seizure management protocol. Staff we spoke with were unaware of the diagnosis, and records showed they had not received epilepsy training. Another person with a pain related condition that could lead to stroke or seizures, did not have a health deterioration protocol to guide staff in recognising warning signs or responding appropriately. This increased the risk of delayed treatment and potential harm.

Emergency planning documentation did not consistently reflect people’s individual needs. Personal Emergency Evacuation Plans (PEEPs) did not include guidance on supporting people with percutaneous endoscopic gastrostomy (PEG) equipment, distressed behaviours, seizure risks, emollient creams that increased fire risk, or the location of the nearest fire exit. The provider told us they had begun reviewing risk assessments and emergency documentation.

The provider did not always detect and control potential risks in the care environment. They did not consistently ensure that equipment, facilities, and technology supported the delivery of safe care. Structured environmental safety systems and maintenance arrangements were not consistently applied in practice, increasing the risk of avoidable harm.

The service had a range of environmental safety arrangements, including Legionella controls, fire safety checks, and up-to-date equipment servicing. Furniture was secured and window restrictors were fitted where required. However, some areas presented unmanaged risks.

Storerooms and sluice rooms were left unlocked on multiple occasions across the 3 days of on-site inspection, and these contained items including chemicals, continence products, and clinical and general waste. In one unlocked sluice room on the dementia unit, exposed hot water pipes were accessible to people with cognitive impairment who were independently mobile and therefore at increased risk of injury. A hot water dispenser was accessible in two units with the activating key left in place. Food trolleys were left unsupervised and switched on in different units, with one recorded at 46.8°C. Alcohol and hazardous substances were stored in unlocked cupboards accessible to people living in the dementia unit. This increased the risk of burns or accidental ingestion of hazardous substances.

Environmental risk controls and equipment checks were applied inconsistently. Integral bed rails remained in place regardless of individual risk assessments. Maintenance records showed staff did not always complete checks when people were asleep. On multiple dates bed checks were recorded as “unable to check due to person being asleep in the bed”, with no evidence of staff follow up. This meant staff could not always be assured that equipment remained safe and appropriately maintained. Following our feedback, the provider told us they had begun reviewing environmental security arrangements and monitoring processes.

The provider did not make sure there were enough qualified, skilled, and experienced staff to meet people’s needs safely. Staff did not always work together effectively to provide care that was safe, supportive, and person-centred. Governance systems to calculate staffing levels and monitor workforce compliance were in place, but gaps in staff deployment, skill mix, and competency limited their effectiveness in practice.

The provider used a dependency tool to determine staffing levels, and records indicated staffing was above the required level. However, staffing deployment did not always reflect people’s needs in practice. During inspection, we observed 4 people with cognitive impairment entering other people’s rooms without staff intervention. Records showed hourly wellbeing checks were completed inconsistently for people who required regular monitoring. This showed staffing capacity did not always support safe supervision or person-centred care.

Feedback from people, relatives, and staff indicated staffing levels affected the quality of care and supervision. One relative told us, “Staff numbers not really enough especially at the weekend,” and another said, “Not enough staff. Skeletal numbers. Easy option for staff to leave [person] in bed.” Sixteen staff members reported feeling short-staffed, which led to task-focused care and low morale among the team. One staff member told us, “People pay so much money to be in a home that looks good but hasn’t got enough workforce to meet their basic needs and that is not right.”

Training and competency oversight did not always ensure staff had the knowledge and skills required to meet people’s needs. The training matrix demonstrated that some staff had not completed Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) statutory training or needs-specific training such as epilepsy awareness. A revised training matrix provided after inspection did not clearly show training completion dates, which limited assurance that staff competencies were current.

In response to these findings, the provider deployed on-site management cover 24/7 and had started reviewing staff deployment, skill mix, and training oversight.

The provider did not always assess or manage infection risks effectively. Staff did not consistently follow infection prevention and control (IPC) procedures, and local controls were not always implemented, reducing assurance that infection risks were consistently mitigated. Structured IPC systems and documented procedures were in place, but inconsistent practice limited their effectiveness.

Policies, risk assessments, and the annual IPC statement were current. Staff had completed mandatory IPC training and could describe the actions required during an outbreak. However, staff did not always follow IPC procedures. We observed personal protective equipment (PPE) and clinical waste was not stored in line with the provider’s policy. We also observed one member of staff entering multiple people’s rooms wearing the same PPE and handling soiled bed sheets without PPE or appropriate laundry bags. This increased the risk of cross-contamination.

Food safety practices were inconsistent. We saw a food trolley left switched on and unsupervised, with food in the lower hot plate measuring 26.4°C. This was below the safe food standard agency hot-holding temperature of 63°C. Food stored in a refrigerator was not dated, which meant staff could not be assured it was used within safe timeframes.

Relatives gave mixed feedback about cleanliness. Some described the environment as well maintained, telling us the home was “clean and tidy” and “spotless”. However, others reported inconsistencies, particularly at weekends. One relative said, “Home is clean in the week but can lapse in the weekend,” and another commented, “Cleanliness can be hit and miss in [person’s] room.”

The provider did not always ensure that medicines were managed safely or in a way that met people’s individual needs, capacities, and preferences. Staff did not consistently involve people in planning or administering medicines in line with individual risk assessments and best practice. Although systems for medicines management were in place, inconsistent implementation, documentation gaps, and unclear protocols meant we could not be assured medicines were consistently optimised and safely managed.

Medicines storage and security arrangements were not always robust. On the second day of inspection, during an out of hours visit, we observed the medicines room unlocked with the medicine’s cupboard open. This allowed unauthorised access to prescribed medicines, sharps, and confidential records. We also saw medicines trolley was also left unattended in the dementia unit’s corridor, with the key in the lock. This increased the risk of medicines misuse, loss, or harm to people.

Medicines records and protocols did not always provide clear guidance for staff. When people were prescribed ‘when required’ (PRN) medicines, protocols lacked detail such as triggers for use, maximum doses, possible side effects, and monitoring instructions. This meant that staff may not have had enough information to administer PRN medicines safely and consistently, increasing the risk of inappropriate use, incorrect dosing, or inadequate monitoring of people after the medicine was given.

Medicines Administration Record (MAR) charts contained inconsistencies. For example, 1 person’s MAR chart contained incomplete allergy information. This meant staff may not have had clear access to important safety information when administering medicines, increasing the risk that a medicine could be given which the person may be allergic to.

Patch rotation guidance that was also not consistently followed. For 1 person prescribed transdermal patches, records showed staff applied patches daily, alternating left and right sides of the back, without documenting removal of the previous patch for 7 consecutive days, despite product guidance recommending avoidance of the same site for 14 days. This meant there was a risk of skin irritation, reduced medicine effectiveness, or potential overdose if patches were not removed as required.

Temperature monitoring records were incomplete, and staff had not escalated out-of-range readings for several months. This meant staff could not always be assured medicines were stored at the right temperature.