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Archived: Orchard Court Inadequate

The provider of this service changed - see old profile

We are carrying out a review of quality at Orchard Court. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating


Updated 25 May 2018

We inspected Orchard Court on 13 March 2018. The visit was unannounced.

At the previous inspection on 23 November 2017, we found breaches of legal requirements and the service was rated inadequate overall and the service was put into special measures. We imposed urgent conditions on the registration which prevented new admissions to the service and required the provider to submit regular reports to prove the safety of people using the service.

After the comprehensive inspection, the provider was asked to provide an action plan to tell us what they would do to meet legal requirements in relation to breaches in person centred care, safe care and treatment, safeguarding service users from abuse and improper treatment, staffing and good governance. The service was also in breach of the registration regulations failing to notify the Commission of events affecting people. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches identified.

At this inspection we found the service had made some of the required improvements. However, the rating for the service remains Inadequate and the service remains in special measures. We found three continued breaches and three further breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Orchard Court is registered to provide residential and personal care for up to 20 people. There are three separate units within the service with six to seven people living on each unit. At the time of this inspection there were 20 people living in the service. There were people using the service who could not always express their needs and wishes because they had a mental health condition or because their ability to communicate was impaired. Many of the people using the service had complex needs which, at times, needed one to one or two to one support from staff who were trained in specific and specialised areas of care delivery. During our inspection it was not evident that support was being provided to the level people needed, to provide both meaningful activities or ensure their safety.

The service had a registered 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.

The staff team had received training on the safeguarding of adults and were aware of their responsibilities for keeping people safe from avoidable harm. The provider’s safeguarding policy had not always been followed when a safeguarding concern had been identified.

The risks associated with people's care and support had been assessed though not all of the assessments had been personalised to cover the individual needs of the person.

The deployment of staff was ineffective and people were not being provided with the support they needed at a time that suited them. The way in which shifts were organised and the necessity for the staff team to carry out cleaning duties meant the people using the service missed out on participating in activities and interests that were important to them.

Appropriate checks had been carried out on new members of staff to make sure they were safe and suitable to work at the service and an induction had been provided. Whilst the staff team had received a number of training courses since our last inspection, some staff members had yet to receive training on specific health conditions people lived with.

People were not always supported with their medicines as prescribed by their GP. Not all of the staff team were aware of which of the people using the service were receiving their medicines covertly. [Disguised in food].

The premises were not clean or hygienic. The staff team were required to carry out cleaning and laundry duties as well a

Inspection areas


Requires improvement

Updated 25 May 2018

The service was not safe.

Inappropriate deployment of staff meant people’s care and support needs were not being routinely met.

Not all areas of the service were well maintained, clean or hygienic.

Medicine records did not always accurately reflect the support people required.

The staff team understood their responsibilities for keeping people safe from avoidable harm.


Requires improvement

Updated 25 May 2018

The service was not consistently effective.

Not all of the staff team had received the necessary training to enable them to meet people’s specific care and support needs. Staff competency was not being checked.

People were not being provided with a nutritionally balanced diet that reflected their needs or preferences.

Whilst the staff team understood the principles of Mental Capacity Act 2005, required documentation was not always completed.

People were assisted to access health care services when they needed them.


Requires improvement

Updated 25 May 2018

The service was not consistently caring.

The staff team were kind and caring though didn’t always involve people in meaningful conversation.

The staff team understood the needs of the people they were supporting though were not given the time to provide support in a compassionate and personal way.

People’s relatives and friends were able to visit at any time.


Requires improvement

Updated 25 May 2018

The service was not consistently responsive.

People were not engaged in activities they enjoyed and their goals and aspirations were not being fulfilled.

There was a lack of emphasis on people reaching their potentials and leading fulfilling lives which encouraged and supported their independence.

People's care records were not regularly reviewed with them or their representatives.

The provider’s complaints process was displayed and people knew how to raise a concern.



Updated 25 May 2018

The service was not well led.

People were at risk of organisational abuse because of how the service was run.

The provider had taken away the opportunity to provide people with individual care and support.

Monitoring systems used to check the quality of the service were ineffective and had failed to identify shortfalls within the service.

The staff team felt unsupported by the provider and continued to lack confidence in them and how the service was being run.