The Old Orchard

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.

This is the first assessment for this service. This key question has been rated outstanding.

This meant people were protected by a strong and distinctive approach to safeguarding, including positive risk-taking to maximise their control over their lives. People were fully involved, and the provider was open and transparent when things went wrong.

This service scored 94 (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 had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The provider demonstrated an exceptionally effective learning culture in which safety was prioritised through openness, reflective practice, and transparency. A well-established no‑blame approach was embedded across the service, creating an environment where staff felt confident to raise concerns, ask questions and explore potential risks without fear. This enabled safety issues to be identified quickly, resolved appropriately, and shared as learning across the service. For example, to reduce the risk of medicines errors and strengthen practice, the service introduced a revised medicines administration protocol focused on accuracy, accountability, and consistency. This included clearer recording systems, additional checks, and improved guidance for staff.

Staff took a proactive and thoughtful approach to monitoring and improving safety. The provider consistently evaluated practice, adapted approaches in response to real‑time learning and reflected on outcomes to drive continuous improvement. Feedback was actively sought from people using the service, relatives, advocates, and staff as part of everyday practice, rather than only following incidents. This ensured learning was embedded early and consistently, supported by personalised social stories to enhance understanding. As a result, improvements to care and risk management were implemented promptly, leading to safer, more effective, and highly person-centred outcomes for people.

As a result, people experienced fewer incidents and developed increased trust in the staff supporting them. People were actively involved in discussions about their own safety and felt listened to. Because staff responded to feedback openly and transparently, people were reassured that their safety was taken seriously and that their views genuinely influenced how care was planned and delivered.

The provider always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The provider demonstrated an exceptional and sustained commitment to safe, reliable systems of care. They worked proactively and in partnership with a wide range of healthcare professionals to maintain safety across all care pathways and transitions. Risks were consistently anticipated and mitigated well in advance, rather than being managed reactively, and systems were thoughtfully adapted to meet each person’s individual communication, health, and emotional needs.

When people attended hospital, staff always accompanied them. They ensured detailed, personalised communication passports were provided to hospital staff. This ensured hospital staff clearly understood how best to communicate with and support each person, meaning people did not need to repeat their history or experiences multiple times. This significantly reduced distress supported truly informed clinical decision-making and minimised the risk of avoidable harm.

Staff showed outstanding confidence and professionalism when advocating for people, including appropriately challenging assumptions and preventing potential misdiagnosis. This resulted in one person being treated for an infection and dehydration when the doctor had previously diagnosed them with low mood, which meant they got the treatment they needed.

Staff had a strong awareness that accessing healthcare services such as GP surgeries, dental practices and hospitals caused significant anxiety for some people. They responded with creativity and compassion, routinely going above and beyond by incorporating visits to these settings into community outings.

This supported people to gradually build familiarity, confidence, and emotional resilience over time. Where this approach was not suitable or possible, the service proactively arranged for healthcare professionals to visit people in the care home. This ensured health needs were met promptly and effectively in environments where individuals felt safe, secure, and empowered.

As a result of these approaches, people accessed healthcare with increased confidence, missed fewer essential appointments and experienced improved health outcomes. Reduced anxiety around clinical settings led to better engagement with treatment and enabled earlier identification and intervention for health concerns.

The provider worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. Staff had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The provider always shared concerns quickly and appropriately.

Safeguarding approaches were highly personalised and based on each person’s individual experience of feeling safe. The management team ensured safeguarding practice reflected people’s preferences, lived experience and any past trauma. This resulted in bespoke, choice‑led risk assessments that balanced positive risk‑taking with protection from harm. For example, staff ensured that one person was able to travel safely with specific strategies to mitigate potential triggers for trauma and distress. This enabled the person to access services and facilities of their choice.

Care planning incorporated people’s personal histories and supported independence, emotional security, and confidence. As a result, people developed greater autonomy, resilience and trust in staff, experienced improved quality of life and felt empowered to pursue their goals safely.

People were supported in line with the Mental Capacity Act 2005 (MCA). Where people required restrictions to receive care and treatment, these were managed lawfully through Deprivation of Liberty Safeguards (DoLS). The Registered Manager demonstrated strong oversight of safeguarding and worked consistently within MCA principles.

Concerns were identified promptly and staff followed organisational procedures correctly, informing the Registered Manager without delay. Risks were assessed proportionately, appropriate action was taken, and referrals were made to relevant external agencies, including the local authority safeguarding team, health professionals, and the Care Quality Commission. Learning from safeguarding concerns was shared with staff, strengthening the service’s safeguarding culture.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

During the assessment, we found the provider consistently demonstrated an exceptionally person‑centred and collaborative approach to risk management. Staff worked holistically with people to ensure support was safe, enabling and clearly focused on what mattered most to everyone, balancing safety with independence and personal goals.

People were always treated as individuals, and positive risk‑taking was actively encouraged. Staff used creative, strengths‑based approaches to support people to pursue meaningful goals. Each person had a trusted keyworker relationship, providing consistency, emotional security and confidence to explore new challenges at a pace that felt manageable. This enabled people to continue horse riding and swimming. Staff were consistently striving for what people wanted to do and how it could be supported safely.

Keyworkers broke goals into small, achievable steps, allowing risks to be addressed gradually and safely. This enabled people to build confidence and achieve milestones such as engaging in new community activities, developing independent living skills, and reconnecting with family routines.

Risks were reviewed consistently with people, ensuring plans remained current and reflected changes in ability, confidence, and motivation. Most families told us they felt actively involved and well supported, which promoted consistency between home and the service and increased confidence in the approach to risk.

As a result, people experienced greater autonomy, improved wellbeing, increased emotional resilience and a stronger sense of control over their lives. Staff consistently supported people to take safe, meaningful risks that enriched their everyday experiences.

For example, when risks were identified in people’s dietary needs, the staff team always involved the person, their family, Speech and Language Therapy (SaLT) and the care team to review the risks and reduce unnecessary restrictions. As a result, the person was able to safely enjoy foods that were important to them again, leading to improved wellbeing and a meaningful enhancement in their quality of life.

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider proactively identified and managed environmental risks and ensured equipment, facilities and technology supported the safe delivery of care. Where required, the provider went above and beyond to adapt the environment, so people felt safe and comfortable in their own space.

For example, by introducing a wet room and tailored water‑play resources, the service took a creative, strength‑based approach that allowed one person to safely continue enjoying water.

This supported emotional regulation, reduced environmental risks, and enhanced personal care outcomes.

To protect food choice, leaders recognised that restricting meal options would significantly disrupt routines, sensory‑preferred foods and established eating patterns that were important to people with autism and learning disabilities. They made a proactive, values‑led decision to secure additional funding within the placement budget to employ a cook. This ensured a safe kitchen environment without imposing unnecessary restrictions and resulted in consistently calm mealtimes, reduced distress, improved engagement, and enhanced wellbeing for people using the service. This maintained choice, predictability and autonomy around food and supported emotional regulation, dignity and independence, and enabled people to experience daily life that was fulfilling rather than restrictive.

The provider made sure there were always enough qualified, skilled, and experienced staff, who received thorough support, supervision, and strong development opportunities. They worked together well to provide safe care that met people’s individual needs.

The provider ensured there were always enough skilled, experienced and well‑supported staff. Strong recruitment, supervision and development arrangements resulted in a stable workforce who worked effectively together to deliver safe, person‑centred care.

Values‑based recruitment and low staff turnover meant people were supported by staff who knew them well and understood their histories, communication styles and preferences. This consistency strengthened trust, reduced anxiety and enabled highly personalised care.

Staffing levels and deployment were flexible and responsive, allowing people to take part in daily activities and access the community. Strategic workforce planning ensured rotas were stable and resilient to unplanned absence, including practical arrangements to maintain safe cover without disrupting people’s routines. As a result, people experienced continuity of care and uninterrupted therapeutic support.

When new staff joined, people were supported through social stories (a communication method) and gradual introductions, ensuring transitions felt safe, familiar, and reassuring. Relatives were proactively informed and provided with pen profiles of new staff to reduce anxiety.

The staff team had a strong skill mix aligned to people’s needs. Training extended beyond mandatory requirements and included people’s individual needs and preferences, condition‑specific learning and wellbeing support. Regular reflective supervision and clear leadership ensured staff remained confident and competent, which improved safety, engagement and health outcomes for people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff had a clear understanding of their infection prevention and control responsibilities and followed safe practices, including good hand hygiene, appropriate use of personal protective equipment (PPE) and robust cleaning routines. Infection monitoring records showed potential risks were identified early and escalated appropriately, enabling prompt action to prevent outbreaks.

Infection control measures were embedded without detracting from the homely environment. Cleaning equipment and PPE were stored discreetly, communal areas remained clean and welcoming, and people’s bedrooms retained individuality while meeting high cleanliness standards.

As a result, people lived in an environment that was safe, hygienic and comfortable, with infection control arrangements that respected their dignity, preferences and emotional wellbeing.

The provider always made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There were processes in place to ensure the safe and effective use of medicines.

People received their medicines safely, consistently, and as prescribed. Medicines were administered promptly, accurately recorded on Medicines Administration Records (MARs), and stored securely. Robust, well‑embedded medicines management systems ensured people were always protected from harm. Staff worked proactively with the GP and other healthcare professionals, holding regular clinical discussions and medicines reviews to ensure regimes remained safe, effective, and responsive to people’s changing needs. This dynamic approach resulted in staff identifying that one person’s medicines had been changed which would have caused significant distress to the person. Staff advocated tirelessly on the person’s behalf to ensure the prescribing professional was aware of the potential impact on the person and the prescription was changed.

Risks associated with medicines were clearly identified and well managed. Individual risk assessments were in place for people prescribed paraffin‑based skin products to reduce risks associated with fire, and clear, person‑specific PRN protocols (including variable doses) enabled staff to administer medicines safely and consistently. Records accurately reflected doses given, supporting effective monitoring and timely review.

Medicines were checked on receipt, with regular stock and balance checks completed. We verified medicine quantities and found them to be accurate. Topical medicines were clearly documented on MARs and supported by body maps to reduce the risk of error. There was a policy for controlled drugs managed in line with national guidance, with consistent balance checks. However, there were no controlled drugs on site during this assessment.

Storage temperatures were monitored and recorded reliably, ensuring medicines remained safe for use. Accurate records were maintained for medicines taken during off‑site visits. There were clear processes for reporting, reviewing, and learning from medicines incidents, supporting a strong culture of safety and continuous improvement.

Staff were well trained and competent in medicines management, with regular competency assessments. Managers and trained staff completed routine audits to ensure systems were followed consistently, resulting in exceptionally high levels of safety and assurance.