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Inspection carried out on 18 August 2020

During an inspection looking at part of the service

The Orangery is a nursing home which can provide care to up to 40 people who are aged 65 and over. People who require general nursing care live on the ground floor, and those who are living with dementia on the first floor. At the time of our visit, 40 people were living at The Orangery.

We found the following examples of good practice.

• Visits were well planned to reduce risk and avoid the potential spread of infection. Visitors received information before coming to the service so they know what to expect. This guidance was clear and personal protective equipment (PPE) was supplied. Visits usually took place in the garden area, but plans were in place to develop dedicated visitor areas as the weather becomes more inclement.

• When people were admitted to the service, current guidance requires that they must isolate themselves from other people who live there. These people were admitted to a room with ensuite facilities and direct access to garden areas to ensure they remained safe but had some freedom and independence.

• One person living at the service had been a musician. They asked if they could provide live musical entertainment when performers could not come into the service. This person performed a number of times during the period of lockdown, received positive feedback and enjoyed this role.

• Staff received additional training and completed competency assessments to show that they understood and followed guidance about infection control procedures such as hand washing and using PPE. The environment had been altered to ensure PPE was used and disposed of safely.

• Initially, staff lived in the service for two weeks then had two weeks off. This was to reduce risk and control the possible spread of infection. The provider considered staffs’ wellbeing and needs during this time and on their return home. For example, the provider supplied a wide range of food, secured hotel accommodation when staff could not return home, and asked a local mental health team to support staff when this was required.

• A handbook which was available for staff about ‘quarantining’ in the service was informative and was translated into several languages. This ensured all staff had a good understanding about expectations.

• Audits were carried out daily and included general infection prevention and control checks, compliance with guidance and staff understanding of procedures and safe practice. Changes were made where needed and managers checked compliance regularly.

Further information is in the detailed findings below.

Inspection carried out on 5 November 2019

During a routine inspection

About the service

The Orangery is a nursing home providing personal and nursing care to 40 people aged 65 and over at the time of the inspection. The service can support up to 40 people.

The Orangery is laid out over two floors, Azalea Wing, supporting people who require general nursing care and Gardenia Wing, supporting people who are living with dementia. Gardenia Wing includes a communal dining area and rooms are set out around the ‘orangery’, a glass roofed space used to accommodate activities. A smaller communal lounge is situated next to the nursing station. Azalea wing offers one large lounge that is converted into a dining space during meal times, when tables are pulled into the centre of the room. All of the rooms offer en-suite facilities and there are communal bathrooms and toilets available for people on both wings. A lift ensures people can access all areas of the home and there is level access to the garden from both floors of the building. The manager’s office is situated adjacent to the communal entrance on the ground floor.

People’s experience of using this service and what we found

People told us they were supported by staff who were kind and caring. We observed many kind and caring interactions between people and staff. Considerations were given to people’s equality characteristics. Staff practice ensure people’s dignity and privacy was respected.

People told us they felt safe. Risk assessments were in place and provided sufficient guidance for staff about how to protect people from potential harm. Staff we spoke with were confident about how they would identify potential abuse and actions they would take if abuse was witnessed or suspected. The home was clean and free from malodours. Medicines were managed safely.

The provider responded to complaints and concerns appropriately, relatives said they felt able to raise complaints and concerns. People received a responsive service that was personalised to meet their individual needs. Activities were available for people and the provider had recently employed an additional staff member to assist with activity provision. People with a disability or impairment were supported to access information that was relevant and important to them.

The provider ensured notifications were sent to the commission in line with statutory requirements. Staff were involved with a research project in partnership with a local university and national researcher. Links with the community included those with a local school and religious organisation. There was a person-centred culture and staff spoke about people in a person-centred and respectful way. Staff told us they worked as a team.

People’s oral healthcare needs were not always assessed and people were not always supported to access dental check-ups in line with published guidance about best practice. People were supported to access healthcare, however there was a risk people may not be supported to access the dentist as required. When fluid targets were in place for people who were considered at risk of dehydration, fluid charts did not always show staff were acting to improve the person’s fluid consumption. However, we did not find evidence that people were dehydrated.

People’s end of life care preferences were explored and the provider had received compliments from loved ones of people who had passed away about the care they received during the end of their life. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We have made one recommendation about oral healthcare assessment and support.

Rating at last inspection Good (published May 2017)

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re

Inspection carried out on 6 April 2017

During a routine inspection

The inspection took place on 06 April 2017 and was unannounced. The service was last inspected in January 2016 when it was compliant with the legal requirements at that time.

The Orangery is a care home registered to provide nursing care and accommodation for up to 40 people, some of whom were living with dementia. The home is located in a residential area on the edge of Bath. There were 38 people living there on the day of our visit.

There was a registered manager for the service. 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.

People were safe in the home and there were systems in place to protect them from abuse and harm. There was enough staff deployed throughout the home to safely meet the needs of the people who lived there. The provider's recruitment procedures helped to minimise the risks of unsuitable staff being employed at the home.

People told us they were cared for by kind staff who they got on well with. People looked relaxed and comfortable in the company of the staff that supported them with their care. Everyone we spoke with praised and spoke highly of the staff that supported them. Staff were observed caring for people effectively and properly meeting their needs. Everyone we spoke with praised and spoke positively of the staff that supported them. Comments included, “The staff are all lovely girls.” “They treat you like part of a family”.

People were supported by a team of suitably trained staff. Nurses went on regular clinical training and updating of their skills. This was to help them know how to provide personal care based on up to date practice.

The staff went on regular training and were developed and supported in their work. This helped the team to improve and develop their skills with people. Staff received supervision which also helped to ensure they were competent in their work. Staff spoke positively about working as a team and the morale that was generally good among them.

People and their relatives had been involved in the planning of their care. The views of people were used to help ensure care was provided in the way people wanted it to be and in a way that met their needs. Feedback about the home from people and others involved in their care was positive. Reviews were undertaken to see where improvements were needed and the service could be further developed. There were systems in place to monitor quality so that people received care that was personalised to their needs.

People knew how to complain and make their views known .The provider sought the views of people and their families about the service. Suggestions were acted upon and changes put in place if needed.

Staff spoke positively of the management structure in the home and the organisation they worked for. They said that the registered manager provided supportive leadership. The staff team told us they were well supported by the registered manager, who spoke positively about their role. Staff said they saw them every day and they were always there and supported them whenever they needed.

Inspection carried out on 27 January 2016

During a routine inspection

The inspection took place on 27 January 2016 and was unannounced. The service was last inspected in 22 August 2013 when it was compliant with the legal requirements at that time.

The Orangery is a care home registered to provide nursing care and accommodation for up to 40 people, some of whom were living with dementia. The home is located in a residential area on the edge of Bath. There were 39 people living there on the day of our visit.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

There was a registered manager for the service. 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 understood how to keep people safe. Risks to people’s safety were properly identified and well managed. There were enough numbers of staff employed to meet people’s needs and help to keep people safe. There were safe systems in use to manage and administer people their medicines.

People told us they were well cared for. They looked relaxed and comfortable in the home and with the staff who supported him. Everyone we spoke with complimented and spoke highly of the staff who supported them. Comments included, “The staff are all lovely and kind.” “They can’t do enough for you they make me feel that I matter to them”.

The staff team were well supported. They were provided with regular training and support to do their jobs effectively. This gave staff the knowledge and skills to meet people’s needs in an effective and individualised way.

The home environment was designed to enable people to move freely around the home. There was a spacious and enclosed seated conservatory area that people told us they enjoyed using.

People and their relatives were involved in the planning of their care. The views of people were used to help ensure care was flexible and provided in the way people wanted it to be.

People and their representatives knew how to make a complaint. There was a system in place to ensure that complaints were managed in accordance with the provider’s complaints policy.

There were quality monitoring systems in place so that the safety and suitability of the service was properly monitored. Action was taken where needed to improve the service.

Inspection carried out on 15 & 17 October 2014

During a routine inspection

We carried out this inspection over two days on the 15 & 17 October 2014. At our last inspection in May 2013 no concerns were identified.  

The Orangery Nursing Home provides accommodation for up to 40 people who require personal and/or nursing care. At the time of our visit there were 39 people living there. The Orangery has two floors each providing specialist care for people who require nursing and/or are living with dementia. Azalea wing which is on the ground floor provides personal and nursing care for people with or without dementia who have long term physical medical conditions. Gardenia wing which is on the first floor provides personal and nursing care for people who are living with dementia.

The home had recently appointed a new manager who was responsible for the day to day operation of the home. They were in the process of applying to become the registered manager of The Orangery. 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 home manager was not present during our inspection.

Staff did not always receive effective induction and supervision. Records we reviewed for staff supervision meetings identified areas of improvement in staff working practices. Where objectives had been set, no actions had been identified as to what would be put in place to address these areas of improvement, such as training or mentoring.  Where dates had been set to review these improvements, these were not until nine or twelve months later. This meant that if staff had not improved their working practices, this would not be identified until some- time after the initial meeting.  This was a breach of Regulation 23 of the Health and Social Care Act 2008 (Regulated Activities) 2010.

Induction workbooks we looked at had not always been completed. Some sections of the workbook had not been completed whilst other staffs work had not been marked. This meant that the manager had not signed staff as being competent following their induction period. 

People’s medicines were administered safely on Azalea wing.  However on Gardenia wing we found that recording of medicines administered was not always accurate. The service had appropriate systems in place to ensure that medicines were stored correctly and securely.

People who were able to told us they felt safe living at The Orangery. Relatives told us they felt their family member was safe and well cared for. Staff we spoke with knew how to identify if people were at risk of abuse and what actions they needed to take to ensure people were protected.

Staff understood the needs of the people they were supporting. We saw that care and support was provided in a kind and supportive manner. People and their relatives spoke positively about the home and the care and support provided. There were two activity co-ordinators who provided activities such as flowering arranging, arts and crafts and trips out. Whilst there was a varied programme of social activities arranged, there was not a clear focus on stimulating or engaging people in provision. Care records did not always clearly identify the needs of people receiving care. This meant that up to date information about people’s care and support was not always available. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) 2010.

People were supported to have sufficient to eat and drink throughout the day. Specialist diets were catered for where people required them.

The provider had systems in place to monitor the quality of the service provided. Staff were aware of the organisation’s visions and values which was to ‘make a happy household’. The operations manager had knowledge of the Deprivation of Liberty Safeguards (DoLS). Deprivation of Liberty Safeguards is where a person can be deprived of their liberties where it is deemed to be in their best interests or for their own safety. The operations manager understood DoLS and where required had made applications to ensure people were supported appropriately.

Inspection carried out on 29 May 2013

During a routine inspection

When we arrived at The Orangery we found the atmosphere calm and relaxed and people beginning to start their day. People were having their breakfast, mostly in their rooms, which was their preference. The home had a lively tea party for the afternoon and had invited people's friends and families.

People we talked with said they were happy with their care. One person said: "the staff are lovely. There's nothing I want for." Another said: "the care is excellent. I have been made to feel very welcome here. My family and friends are also made welcome at any time." We were also told by someone who had lived at the home since it opened in 2012: "the care is very good. It couldn't be any better."

We found the staff were knowledgeable about gaining people's consent. They had put their training and experience into practice to make sure they acted in accordance with people's wishes. Staff also understood how to use the provisions of the Mental Capacity Act 2005 to support people with limited or no mental capacity.

Staff planned people's care and ensured it met their needs. The home cooperated with other providers of health and social care to make sure care was coordinated if it was shared with or transferred to another provider. There were enough staff of the right mix of skill and experience to meet people's needs safely. We found the home clean, hygienic, and well maintained. Staff knew how to care for people to control and prevent the spread of infection.

Inspection carried out on 23 August 2012

During a routine inspection

When we visited The Orangery on 23 August 2012 we spoke with some people living at the home. A high proportion of people were living with dementia or other cognitive impairment and not able to tell us their views. We did, however, meet some people who were able to tell us about their experiences. We also met and talked with four visitors who had come to see their relative.

One person we met said: �I would not change anything. I am happy here and would not want to move as I wouldn�t find anything better�. Another person said: �I am looked after very well. The food is good and the staff are kind�.

One visitor we met told us: �the place is perfect and I have no concerns�. Another who was a healthcare professional said: �I don�t think we could have picked a better home�. Two visitors told us the home had improved but they still had some concerns in a number of areas around people have enough activities and stimulation in their day. They also were concerned as to whether their relative was getting coordinated care in relation to having enough to drink.

We observed a busy and lively lunch and people appeared to be enjoying the food. All the people we talked with said they enjoyed the food. They said they were given a variety of meals and could choose them each day. They said they were able to ask for something different if they did not like what was on the menu that day.

We observed care delivered by the nursing and health care staff with patience and kindness. People were almost always treated with dignity and respect.