Orchard House Care Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

We found one breach in regulations in relation to good governance at the service.

Leadership and governance arrangements did not provide effective oversight. Systems to monitor risk management, staffing, medicines, safeguarding, and care quality were ineffective.

This service scored 39 (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 promote a shared vision, strategy, or culture that reflected transparency, equity, human rights, diversity, and inclusion. While the service had a defined mission, purpose, and policy framework—including an equality and diversity policy—inspection findings and staff feedback indicated these values were not consistently demonstrated in day-to-day practice.

Staff feedback highlighted concerns about workplace culture and leadership behaviours. Nine staff members described a culture of fear, blame, or reprisal, which affected morale, teamwork, and confidence in raising concerns. Sixteen staff members reported emotional exhaustion and division within teams, limiting their ability to work together and deliver care aligned with the service’s stated values.

This meant we could not be assured staff felt safe to speak up, share concerns, or contribute to service improvement. They also impacted the consistency with which staff understood and responded to the needs of people using the service and their communities.

Although policies and organisational statements described shared values, these were not consistently embedded in everyday practice. As a result, the provider could not demonstrate that the intended culture was fully understood or experienced by all staff or people using the service.

Leaders did not consistently demonstrate the skills, knowledge, and behaviours required to manage the service effectively or model the culture and values expected within the organisation.

Staff feedback about leadership behaviours and confidence in management was varied. Some staff described the most recently appointed deputy manager as supportive, compassionate, and attentive. However, most staff reported that the registered manager was intimidating, dismissive, or difficult to approach, including occasions of being shouted at in communal areas, publicly reprimanded during meetings, and receiving belittling messages in group communications. Three relatives also told us that the registered manager could appear dismissive when concerns were raised.

Frequent turnover of deputy managers contributed to instability within the leadership team, which some staff told us, they felt was impacted by the management approach. These factors reduced staff confidence in leadership, affected morale, and limited the provider’s ability to consistently foster an open, inclusive, and supportive culture.

However, the service had defined leadership roles and governance processes. Records demonstrated some professional development through supervision and appraisal, and duty of candour processes showed transparency in responding to certain incidents. The registered manager left the service after our inspection and the provider told us they had appointed a interim manager and that they were working towards restructuring leadership to ensure that all leaders were capable, compassionate and inclusive.

People did not feel they could speak up and that their voice would be heard. Although the provider had a Freedom to Speak Up policy aligned with national guidance and had appointed a Freedom to Speak Up Guardian, these arrangements were not consistently effective in practice.

Staff told us they felt reluctant to raise concerns due to previous experiences where feedback had been met with defensive or negative responses from leaders. Although 7 members of staff told us they felt comfortable raising concerns, 9 staff reported that annual surveys and other formal feedback opportunities were sometimes followed by meetings where concerns were challenged or criticised by the registered manager, rather than explored constructively. This discouraged open discussion and contributed to staff feeling fearful about raising issues or expressing honest views.

Confidence in the Freedom to Speak Up process was also affected by perceptions about independence. Some staff felt the Freedom to Speak Up Guardian may have a potential conflict of interest due to a close personal relationship with the registered manager, which reduced trust that concerns would always be handled impartially.

Staff also reported occasions where safeguarding concerns were not always escalated externally when required. This meant we could not be assured concerns would be addressed and created risks to transparency, accountability, and the safety and quality of care.

Following the inspection, the provider reported they had appointed an additional Freedom to Speak Up champion and introduced additional management cover to provide alternative routes for staff to raise concerns and strengthen oversight.

The provider did not always demonstrate that workforce diversity was consistently valued or that an inclusive and fair culture was embedded in daily practice.

Staff feedback highlighted inconsistencies. Four staff told us that they had to actively advocate for reasonable adjustments rather than these being proactively identified and implemented by management. Several staff raised concerns about perceived favouritism and unequal treatment, with nine staff specifically described a strong perception of preferential treatment by the registered manager. These issues indicated that fairness and equity were not consistently upheld across the workforce.

However, the service had policies and training in place to support equality, diversity, and inclusion, and in some cases reasonable adjustments were implemented appropriately. Staff demonstrated awareness of the importance of an inclusive workforce.

The provider did not have effective systems of governance, accountability, or oversight to ensure that care was consistently safe, effective, person-centred, or compliant with regulatory requirements. Policies, procedures, audits, and quality assurance frameworks were not consistently implemented, and failed to identify, escalate, or address significant risks.

Monitoring systems were not effective in identifying gaps in practice or driving improvement. Audits relating to medicines management, infection prevention, nutrition, hydration, and clinical observations frequently failed to detect unsafe practices, including delayed or missed clinical observations, incomplete fluid and nutrition monitoring, unsafe medication storage, and inconsistent use of personal protective equipment. Communication systems between units and across shifts were also ineffective, leaving staff sometimes unaware of significant events, such as hospital admissions, deaths, or changes in people’s care needs. This resulted in poor coordination and reduced continuity of care.

Workforce management systems were not effective in ensuring staff could consistently deliver safe and person-centred care. Although dependency assessments indicated staffing levels were sufficient, observed practice showed delays in responding to people’s needs and missed opportunities for engagement. This indicated that the dependency tools being used was ineffective.

Care was often task-focused rather than proactive or personalised. Training, supervision, and risk assessment systems were inconsistently applied, meaning staff were not always supported to develop the skills and confidence required to meet people’s complex needs safely.

Systems for learning, improvement, and risk management were ineffective. Serious incidents, including hospital admissions, medication errors and safeguarding concerns were not consistently escalated, reviewed, or used as learning opportunities. Quality assurance processes did not lead to sustained improvements, and we identified repeated breaches of regulations. This meant risks to people’s safety and wellbeing, including falls, dehydration, malnutrition, distress, and restrictive practices, were not consistently mitigated.

The provider did not have a robust and reliable framework to ensure safe, effective, and person-centred care. Oversight systems were ineffective, leadership did not consistently foster a safe and supportive culture, and monitoring processes failed to identify or address risks in a timely way. This placed people at risk of harm and resulted in inconsistent care experiences, reduced staff confidence, and concern among relatives about the safety and quality of the service.

The service did not consistently ensure that partnership working translated into coordinated care or improved outcomes for all people.

Although the service engaged with external partners and agencies, internal communication gaps, inconsistent care practices, and lack of oversight limited the overall effectiveness of collaboration. As a result, while individual interactions with partners were positive, the impact on residents’ care was variable and did not always fully mitigate risks or support seamless integration with external services.

However, records showed that referrals were made appropriately, and joint working was in place to support people’s care. Feedback from healthcare professionals reflected positive collaboration, with staff being described as knowledgeable, helpful, and proactive in reducing unnecessary emergency calls.

The provider did not demonstrate a consistent focus on continuous learning, improvement, or innovation across the service. Systems intended to monitor quality and drive improvement were not effective in identifying, addressing, and learning from issues in practice.

We found concerns identified during previous inspections, including care planning, risk management, staffing, governance, activities, and personal care, remained at this inspection. This showed lessons had not been fully learned or embedded into practice.

Although leadership reported that internal quality monitoring visits and audits were conducted, these had not resulted in sustained improvements in practice or outcomes for people. Staff had access to professional development opportunities. However, there was limited evidence that learning from training, incidents, feedback, or external guidance was applied to improve service delivery.

This meant the provider did not consistently foster a culture of continuous learning, shared best practice, or innovation. Systems for monitoring, evaluating, and improving the service were ineffective, limiting improvements in equality of experience, care outcomes, and quality of life for people living at the service.