Orchard Manor Care Home

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 Good. This meant people were safe and protected from avoidable harm.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Management had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Management carried out root cause analyses for accident and incidents. The registered manager told us, “We address things there and then. We discuss each person when it happens and check the care plan to see if anything else has happened previously. This will help us make decisions. For example, [person’s name] can become quite agitated if they find themselves in the wrong place. We have learnt how to respond to them in a different way to help reduce that.”

Discussions around accidents and incidents took place with staff and during handover meetings so any changes to a person’s care was shared amongst the team.

Staff worked with people and healthcare partners to establish and maintain safe systems of care, where safety was managed or monitored. They made sure there was continuity of care, including when people transitioned between different services. A relative told us, “As a family we were stressed and concerned that mum’s fall would be an issue, but [registered manager] and her team went out of their way to support us as a family so the transition from hospital to Orchard Manor was smooth. Arranging, mobile dentists, private physio, transportation etc.”

People were assessed prior to moving into the service and once living at Orchard Manor Care Home this continued and relevant changes were made to support the person. Assessments were carried out at the person’s home or at hospital and additionally some people came to the home for their assessment to be done whilst they were visiting the service. All of this helped ensure that staff had as much information about the person as possible prior to them moving in.

Staff worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated 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 shared concerns quickly and appropriately. One person told us, “They (staff) would not have you hurt for the world.” A relative said, “He is very safe here.”

Staff received training in how to recognise potential abuse and put this training into practice. Staff told us, “If I saw bruises I would report to the senior in charge. Sometimes it can happen, and I would have no hesitation in reporting as it is our main duty to keep people safe”, and “[Registered manager] will do the report, but all staff need to be vigilant to report concerns.”

Where incidents of potential abuse had occurred, these were reported to the relevant safeguarding authority, as well as the CQC, and internal investigations were undertaken. The registered manager worked with the local authority safeguarding team to provide information on any investigations that took place.

Staff did not always work with people to understand and manage risks by thinking holistically.

People’s individual risks were recognised but records were not always well kept by staff. One person was at risk of constipation, and staff needed to record their bowel movements daily so health professional input could be sought if needed. This same person also required repositioning in bed every 2 hours. Although we had no concerns that staff were not monitoring the person’s bowel movements or repositioning the person, poorly kept records meant staff may not immediately notice early signs of deterioration or know whether care has been delivered.

There was, however, guidance in place in people’s care plans for staff in order to help keep people safe. One person could not use their call bell, and instead, a live link sensor had been placed in their room to alert staff at night so they could offer assistance. In addition, the person had a crash mat placed beside their bed to reduce the risk of injury should they fall. Other people had good guidance in place regarding their individual risks. People also told us they felt safe. People said, “Definitely feel safe. It’s because they (staff) watch us all the time. If they see you doing something that you shouldn’t, they come straight away”, “I did used to trip quite a bit, but I don’t know. They (staff) are aware of that” and “I have a neck pendant to alert staff if I need them.”

Staff detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff maintained a fire evacuation bag in the front lobby containing up-to-date information for use in the event of the emergency services attending. In addition, weekly fire alarm tests and monthly fire drills were carried out with both day and night staff. This helped ensure that staff were prepared and knew how to respond to situations, such as a fire. Staff carried walkie-talkies to enable them to communicate with each other wherever they were in the building. This helped staff respond more quickly to people who may need help.

Various checks were carried out in the service and on the building to help ensure people were living in a safe environment. This included flushing through water systems to reduce the risk of Legionella, servicing equipment such as the lift, hoists and beds, checking people’s wheelchairs monthly and checking the call bell system was in full working order.

Feedback from staff indicated management did not always make sure there were enough qualified, skilled and experienced staff.

Management set staffing levels using dependency assessments to determine the number of staff needed. However, even though staffing matched these calculations, some staff still felt there were not enough staff on duty each day. They told us, “We knowingly have to not fully attend to people at times because there are not enough of us. People are in bed longer in the morning than they need to be because people require 2 staff to hoist them. It leaves no one in the lounge making sure people are safe”, “Not enough staff because you can’t be caring for everyone at the same time. There was only me on the floor this morning. People are getting up between 8am and 11:30 – we cannot take people to the toilet always as well”, “Sometimes there are not enough staff” and “I feel I cannot always give good care and I feel sad as I have to leave people in bed longer in the morning.”

Staff felt that not having someone in the lounge at all times may put people at risk. During the morning we observed few staff in the main lounge; only the activity staff member was present, with a senior staff member briefly entering the lounge, and no care staff were seen until lunchtime. In the afternoon upstairs, 1 staff member took a person for a walk, leaving 2 people with no staff present. However, the feedback from people and relatives was positive. They told us, “They’re quick”, “They don’t take long as they watch us all the time”, “It doesn’t take long to get help”, “Most times I think there is (enough staff)” and “If anything is needed, they don’t need to wait long.”

We reviewed the call bell audits for a period of 3 months (August to October 2025) and found that, in the main, call bells were answered by staff within the expected target time. We could therefore find no immediate impact to people from staff levels, which meant feedback from staff as opposed to people may indicate an issue with staff deployment at pinch points, like the morning and lunchtime, rather than staff numbers.

Staff received effective support, supervision and development. Staff told us they had the opportunity to meet with their line manager through supervision. One told us, “It is good. It is an opportunity for us to talk through how we are doing.” In addition, staff went through a rigorous induction, probation and training programme with both e-learning and face to face training and 2 weeks of shadowing a more experienced member of staff. A staff member said, “(The training) was good. It helped me to do the job.”

Staff were recruited through good processes. Checks were carried out, including references and staff members’ right to work in the UK. Staff also went through a Disclose Barring Service (DBS) check to help ensure they were suitable to work in this type of service.

Staff assessed and managed infection risks. Although we identified a couple of issues, these were addressed immediately by the registered manager. The service was clean and tidy, and people and relatives were satisfied with the home’s cleanliness. They told us, “It’s very clean and the laundry is absolutely brilliant”, “The home is immaculately clean” and “My mum’s room and the communal areas are always clean, tidy and well-maintained.”

Staff followed appropriate processes in relation to the personal protective equipment they used (PPE). The registered manager told us, “Staff do not wear their uniforms to and from work. We have gloves available for staff in every single room, and have aprons and masks too. The senior staff member on duty at night does a regular infection control audit, which covers checking all PPE. Staff use black cloth aprons when serving food, and items such as medicine pots or urine bottles are disposable. People told us staff wore PPE with 1 saying, “They always do it when they’re touching me or doing anything like that” and another telling us, “They wear gloves when they put cream on my legs.”

Management did not always make sure that medicines records met people’s needs, capacities and preferences.

We found the medicines trolley and clinical room clean and tidy, and staff were checking that medicines were stored at the manufacturer’s recommended temperatures. However, records for medicines were not always well recorded. This included where people were on time-sensitive medicines. Although the service used an electronic medicine system which stated when the medicines should be given, there was no facility to record the actual time the medicine was administered. This meant there was a risk that medicines might be administered too early or too late. Although, staff told us the system did show an alert if a medicine was overdue, or being administered before it should be.

Where people had allergies (particularly 1 person who had a severe allergy to a particular food) this was not always recorded on their medicine administration record (MAR).

People, however, told us they received the medicines they needed. One said, “They bring it in in a little pot. I know they know what they are doing” and another told us, “They bring a pot around with 5 (medicines) in and a beaker of water. They watch you – no getting away with it. I’m happy that they are competent.”