Archived: Orchard Court Care Home

This inspection was unannounced and took place on 4 October 2016.

Orchard Court is registered to provide accommodation with nursing and personal care for up to 44 people. The home was purpose built and the accommodation was arranged over one level. The home is situated in a quiet residential area and has ample parking space.

At the time of the inspection there were 20 people living at the home although not all were able to engage in conversations with us due to their dementia or mental health problems. People had a range of complex nursing care and support needs.

The service did not have a registered manager, however there was a deputy manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

On the day of the inspection the home was being managed by a regional manager who was supported by a managing director. The managing director informed us there would be a regional manager supporting the deputy manager and staff at all times in the absence of a registered manager. Plans were in place to establish a new registered manager.

At the last inspection on 12 March 2015, we found there were breaches of legal requirements and the service was rated Requires Improvement. This was because some procedures and processes were not in place to make sure people were protected. For example, local safeguarding policies and procedures were not always being followed. Systems to assess, monitor and improve the quality and safety of the service were not effective enough. Systems and checks were not in place to monitor the cleanliness of the environment. The provider had submitted an action plan telling us how they intended to improve.

At this inspection we found, although the provider had followed their action plan and made improvements, some risks still remained. People and their relatives said they felt safe however we found areas that require improvements. For example people who required support with eating and drinking, to keep them safe, had been assessed by the speech and language team (SALT). However, the guidelines within the care plans were not always being followed. We also found whilst there were a number of audits and checks being carried out they had not been effective at identifying the issues found at this inspection.

The provider had however made improvements regarding infection control and there were effective systems and checks to monitor the cleanliness of the home. Cleaning schedules were being followed and checks were completed.

The provider had also made improvements to ensure people had access to call for assistance when required. People had call bells and on the day of inspection, the bells were answered promptly. However some people felt they still had to wait a while to be supported with personal care requirements.

People's needs were assessed prior to moving to the home to ensure the service could provide the necessary care and support. Each person had a comprehensive care plan based on their assessed needs. Care plans provided the necessary information for staff to enable them to respond to people's individual needs. People and their relatives told us they had been involved in the assessment and review of care following admission to the home. People’s risks were assessed and recorded and had a review date set, this ensured that assessments were current and accurately reflected the needs of the person.

People were supported by sufficient numbers of staff. The managing director told us they adjusted the staffing levels to meet the needs of people living at Orchard Court, for example a dependency check was completed at the home on a daily basis. They said “Staff sign in to the home through a key system, this will alert me if there are insufficient staff to support. I will authorise agency if I feel the skill mix of staff is wrong or if staff would be unable to support people safely.” People felt they were supported by staff who they knew and who knew them.

Recruitment procedures were in place and staff underwent pre-employment checks before starting work with the service. New members of staff received an induction which included shadowing experienced staff before working independently. One member of staff said, “My induction was good I felt very supported by all my colleagues”, “I have done e learning and mandatory training, I understand about safeguarding I would know what to do if I needed to”.

Staff received training to ensure they had the knowledge and skills to provide effective care in line with current best practices. This included mandatory training, such as: safeguarding, the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, first aid, infection control, fire safety, moving and handling, and understanding dementia. Person specific training was also provided to meet people's individual needs, including dementia, person centred care, and communication.

Throughout our inspection staff showed kindness and consideration to people. When staff went into any room where people were they acknowledged people. Staff had a good rapport with people and were seen to be friendly.

Medicines were administered safely by staff who had received medication training. Safe procedures were followed when recording medicines and medicines administration records (MAR) were accurate and held dated photos of the person. Medication audits were completed and appropriate actions taken to monitor safe administration and storage.

People were able to take part in activities with minimum risks to themselves and others. The coordinator told us that they had plans for the service development including the recruitment of volunteers, further community involvement and the possibility of obtaining a mini bus for day trips.

Systems were in place for responding to people's concerns and complaints. People and relatives told us they knew how to complain and felt assured that staff would respond and take action to support them.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

This is a summary of what we found:

Is the service safe?

We found the service to be safe because the provider had addressed the areas of non-compliance we identified at our last inspection. Care and treatment was planned and delivered in a way that ensured people's safety and welfare. Care plans included a range of individual risk assessments and agreed actions for managing these risks. These included reducing the risk of falls, skin damage and malnutrition.

The provider had a range of policies and procedures in place to protect the people who lived in the home. The staff we spoke with had a good understanding about how to report any concerns.

We observed that staff were competent and professional in their interactions with people who lived at the home. During our inspection we observed people were relaxed and appeared very content with the care and support provided.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made and how to submit one.

Staff carried out regular health and safety checks to make sure that the building was maintained to a safe standard. These checks included testing the fire detection system and hot water temperatures.

Is the service effective?

Following our last inspection care plans had been reviewed and these now contained up to date information for staff about people's needs, risks and preferences. We observed staff supported people in accordance with their plan of care.

We saw that where people had been assessed as being at high risk of pressure damage to their skin, they had been provided with appropriate pressure relieving equipment. We also saw people were supported to change position at assessed frequencies. We read the care plan for one person who was being treated for a pressure sore. This contained photographs and information about the size and status of the wound and details about the prescribed treatment. Records showed this person received appropriate treatment which was in accordance with the prescribers instructions. This meant the effectiveness of the treatment could be appropriately reviewed.

We saw staff recorded information about each person on a daily basis. Information included how people had spent their day and how they had responded to activities of daily living. This meant the effectiveness of people's care plans could be fully reviewed.

Is the service caring?

Staff interacted with people in a gentle and kind manner. People who lived at the home and visiting relatives were complimentary about the staff who worked at the home. Comments included 'the staff are so very kind', 'I like the staff' and 'I can't grumble about anything. I feel well cared for and the staff are very pleasant.'

Is the service responsive?

The service was responsive to people's needs. We saw staff were responsive to any changes in people's well-being. For example we read a person's care records in which staff had recorded concerns about their difficultly in swallowing fluids. We saw staff had requested a GP visit which had resulted in a referral to the speech and language team. We also saw the person received thickened fluids as prescribed by the GP.

The staff we spoke with were knowledgeable about the needs and preferences of the people they supported. They knew about the things which were important to people.

Information about people's health needs and contact with health and social care professionals had been recorded.

Is the service well led?

There was a registered manager in post. A registered manager is a person who has been registered by the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider.

At the time of our inspection the registered manager was on long term leave and the deputy manager had recently left employment. We were informed that one of the provider's regional managers provided management support two days a week. A registered manager from a sister home also based themselves at the home two days each week. We were informed that a peripatetic manager would be providing full time management cover starting next week.

We found staff morale was variable. Staff made the following comments 'I definitely think things have improved. Things seem more organised' and 'It doesn't feel as rushed as it used to.' However some staff told us 'some things have improved but it is really hard with no permanent manager at the moment. You don't know if you are coming or going' and 'you just don't know who to go to at the moment.' We shared this with the visiting manager and company deputy director during our visit.

A record of formal supervision sessions for staff had been maintained and we saw staff supervisions had either taken place or were planned to take place. We looked at the personnel files for two members of staff. Supervision records showed their skills and competencies had been reviewed and that they had been able to discuss any training needs. This meant that systems were in place to monitor the skills, competencies and performance of the staff who worked at the home.

We saw that one of the provider's regional managers carried out monthly audits on the quality of the service people received. Audits included the management and administration of people's medicines, care planning, health and safety and the environment. Following concerns raised at our last inspection, the regional manager had carried out an audit of the lunch time experience for people. At this inspection we saw that recommendations had been implemented. These included offering people visual meal choices and improving the deployment of staff.

The registered manager was not available for this inspection. We were able to meet with the deputy manager and they provided us with all the records we requested. At the time of our visit 30 people lived at the home. This included one person who was in hospital.

We met with the 29 people at the home although not all were able to engage in conversations with us due to their dementia or mental health problems. We spent the duration of our visit observing how people spent their day and how they were supported by staff. We were also able to speak to staff about the experiences of the people who lived at the home.

We observed staff assisting two people from a chair to a wheelchair with the aid of a mobile hoist. Staff appeared confident and competent in the task and we heard them reassuring the individuals throughout the transfer. Staff told us they had received training and refresher training in moving and handling procedures.

During the morning of our visit we found the majority of people were in their bedrooms. Throughout our visit we observed staff were very busy assisting people with personal care needs. We saw staff spent little quality time with people. We did not observe any opportunities for social stimulation.

We received concerns about how people's diet and fluid intake were monitored. We spent two hours observing the lunch time experience for people. We saw that 17 people were assisted to the dining room for their meal and 12 people remained in their bedrooms. The majority of people required staff assistance or prompting to eat their meal. The lunch time experience did not promote people's well-being. We saw some people had to wait for long periods before their meal was served.

People were not protected against the risks of unsafe or inappropriate care because care plans were not always reflective of people's needs.

Diet and fluid intake charts were not always reflective of the food and drink actually taken by people. We observed one occasion where a member of staff had left an individual with a drink and had recorded on the intake chart that they had finished all of the drink before the individual had started.

The staff we spoke with and observed demonstrated a good understanding of the needs and preferences of the people they supported. We met with two visitors. Both were complimentary about the care their relative received and of the staff who worked at the home. They said 'I am very happy with everything here. I don't think they could be better really."

We found that the home had taken appropriate action to ensure that staff received the supervision and training they needed. This enabled them to meet the needs of the people who lived at the home. Staff spoken with were positive about improvements at the home and of the training and support they received.

At our last inspection we found that people's care records did not always reflect their current assessed needs. At this inspection we saw that the home had implemented their action plan which meant that risks to people were minimised.

Staff interacted with people in a kind and respectful manner. People were assisted with personal care in a discreet manner. People were supported to make choices such as how to spend their day and what they would like to eat.

We were informed that there was nobody at the home who was being treated for a pressure sore. Risk assessments and a plan of care were in place for people assessed at high risk.We saw that people had access to appropriate pressure relieving equipment. People's weights had been monitored and we saw that appropriate advice and treatment had been sought where concerns had been identified.

The home had policies and procedures for recognising and reporting abuse and whistle blowing for staff. All staff spoken with were very clear about the types of abuse and how to report any worries or concerns.

Staff spoken with told us that they were able to meet people's assessed needs with the numbers of staff on duty. The home did not have effective systems in place to support and monitor staff through supervision sessions. Some of the care records we looked at had not been updated to reflect people's current needs.

The majority of our inspection was spent with the people who lived at the home. The majority of people we met with were unable to engage in conversations with us. We were however able to see how staff interacted with people and we spoke with staff to find out about the experiences of people who lived at the home.

People appeared very comfortable in the presence of staff and it was evident staff knew people well. Staff were observed being kind, caring and patient when they supported people. The atmosphere in the home was relaxed and happy. Staff responded promptly to any requests for assistance.

We saw that people had been provided with choices about all aspects of their daily lives and that they had the opportunity for social stimulation.

Staffing levels, the skill mix of staff and staff training had been reviewed since the last inspection which meant that people's needs could be appropriately met.

People who were able to express a view made the following comments; 'I am very happy here and the staff are lovely' and 'I am very well looked after. I don't have any worries.' We spoke with a visitor who was very positive about the care and support their relative received.