- Care home
Orchard Court
We served a warning notice on Roseville Orchard Court Limited on 08 June 2026 for a period of 3 months for failing to ensure effective governance was in place at Orchard Court.
Assessment report published 19 June 2026
Contents
Ratings
Our view of the service
Date of assessment: 15 April to 7 May 2026. Orchard Court is a care home which can accommodate up to 43 older people. When our assessment started, 33 people were living at the service. The assessment was carried out due to the length of time since the previous assessment.
A new nominated individual had taken over the care home in November 2025. The provider’s systems did not ensure medicines were managed safely. Records did not demonstrate people received their medicines in line with the prescriber’s instructions. We found some medicines were crushed and were unsafe to do so. Staff did not escalate when medicines errors had occurred for advice to be sought and investigations undertaken. The provider did not have records to demonstrate staff competency to administer medicines safely had been assessed.
Systems were not established to ensure staff were equipped with the required training for their role. Parts of the environment were not well-maintained or cleaned effectively and staff did not always promote best practice with infection prevention and control. Whilst essential checks of fire equipment were in place, the service’s fire risk assessment had not recently been reviewed and there were some outstanding actions from the last assessment. The provider had not ensured contemporaneous records were completed including accurate completion of daily records and consistent information within people’s care records. Care records also lacked person-centred detail to guide staff practice. People had not always been included in discussions about their care and afforded the opportunity to say what they wanted.
The provider was passionate about making improvements at the service and had a programme of refurbishment and had already started taking actions to address elements of the environment including fixing the roof and installing a new kitchen. There was a new manager in post. Although staff hadn’t received regular supervisions, they felt supported, and told us the manager was approachable and visible. The management team were responsive to the feedback and started to take corrective actions including a detailed check of medicines, arranging staff training sessions and organising risk assessments for parts of the premises.
We found the provider was in breach of legal regulations relating to safe care and treatment and governance of the service.
In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.We have also asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
Most people felt staff were kind and respectful in their approach. One person told us, “They are kind and caring. They always knock on your door. They will do anything for you.” Another person stated, “I like the staff and I get on well with them. They are honest and treat you with respect and dignity.” We observed staff speak warmly to people, placing a reassuring hand on their shoulder and suggesting ways they could support them.
However, we received mixed feedback about staff responsiveness. Some people noted they responded quickly whilst others reported delays or needing to chase requests several times. We observed an instance where a person’s dignity was not promoted, which we discussed with the manager and they agreed to address. Furthermore, whilst people told us their choices were respected, they noted they had not been involved in reviewing their care plans or asked about the running of the service. The management team aimed to address this through holding meetings and sending questionnaires to people for further feedback. People and their relatives did, however, feel comfortable in approaching the staff or manager if they had any concerns.
We observed the food looked and smelt appetising and people enjoyed it. People were mostly positive about the quality of the meals and one person stated, “The best thing is the food.”
People and their relatives spoke positively about the process of moving into the service. For example, a relative stated, “[Person] was made very welcome when they arrived and was given tea and cake. Other residents introduced themselves and they seemed to go back to their old self.