Orchard Court

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

This means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of the legal regulations in relation to safe care and treatment and governance.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive culture of safety. Staff did not always identify and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Staff had not always recognised potential safety issues including medicines administration and infection prevention and control practices. Following accidents and incidents, although staff completed records, these lacked sufficient detail regarding preceding events and learning points, including reflective practice. However, staff appropriately sought help and advice when accidents occurred. The provider’s systems were not fully established or operated effectively to ensure any issues including gaps in staff knowledge and inconsistent or incomplete care documentation was identified and addressed.

Whilst previous learning from accidents and incidents was limited, the provider had started to bridge this gap. For example, a detailed falls analysis had recently been introduced which considered actions which could mitigate potential risks for people and identified potential themes and patterns. This required further embedding to improve staff practice and promote safety and learning.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People were assessed as part of their admission to the service to ensure their needs could be safely met. People who had recently moved into the service and their relatives shared positive feedback about the admission process noting they felt well-supported and warmly received by staff.

An effective safeguarding system was not fully established to ensure staff could support people at risk of abuse, discrimination, avoidable harm or neglect. Staff worked with healthcare partners and the provider shared concerns appropriately.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes this is usually through the MCA application procedures called Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA and whether appropriate legal authorisations were in place when needed to deprive a person of their liberty. Applications were made appropriately to deprive people of their liberty. When a DoLS is authorised, conditions are added which are specific instructions for the care home to follow to further protect a person’s rights. The provider did not have oversight of conditions associated with any authorised DoLS, which posed a risk that people’s rights may not be upheld. Records of capacity assessments also lacked detail about how assessments were completed and how best interest decisions were discussed. The provider told us they had identified these issues and would take action to address them.

Records of staff completing safeguarding training were not in place. The provider had not fully established routes to assess staff understanding and competence in safeguarding. This meant the provider could not be assured of staff knowledge. The staff we spoke with said if they observed any concerning practice, they would not hesitate to report this and expressed confidence the manager would act. Safeguarding referrals were made to the local authority for them to investigate. We discussed the need to inform CQC of safeguarding referrals in a timely manner.

People and their relatives told us they felt safe at the service, comments included, “I feel safe because there are a lot of people around” and “They’re all very good, they wouldn’t see you stuck.”

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe and enabled people to do the things that mattered to them.

Although risk assessments were in place for areas such as moving and handling and skin integrity, information within people’s care records was not always consistent and did not demonstrate that people had received support in line with their assessed needs. For example, there were limited records to show that some people had been checked overnight or had received support with their personal care. Further work was also required to ensure people were involved in discussions about their lives and potential risks.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The environmental and maintenance checks completed had not consistently identified and addressed potential risks in a timely manner. For example, fire doors and records of fire drills were not always in line with fire safety requirements. The provider had not ensured the service’s fire risk assessment had been reviewed to confirm it remained appropriate and up to date. The provider had started to take actions to address the fire doors during the assessment and had plans to strengthen fire safety practice including arranging a further fire risk assessment. Essential fire safety checks were completed of equipment including the fire alarms. Information was available to support people in the event of an emergency. Checks of bed rails were completed but were not sufficiently robust, sensors were not checked to ensure these were in safe working order and window safety checks were not in line with best practice.

A new nominated individual and management team had taken over the service, and the nominated individual noted the extensive work that had been undertaken to address the building issues including the installing of a new kitchen and call bell system. There were further plans to develop the building, including fitting new doors from the dining area to the garden so people could freely access this. A new maintenance manager had recently been appointed with responsibility for ensuring the building and equipment were properly checked and maintained within appropriate timescales.

The provider did not always make sure that staff were trained, skilled and experienced for their role. They did not always make sure staff received effective support, supervision and development.

The induction process for new staff was not robust. Their skills and knowledge were not consistently checked or observations of practice recorded to ensure staff provided consistent care. However, new staff noted they were observed and spent time shadowing experienced staff so they could build their knowledge of people and the running of the service. The provider kept a training matrix as an overview of all staff training, but this was not available on site and failed to demonstrate staff had the required knowledge for their role. On occasions, agency staff were utilised to ensure safe staffing numbers. However, information about their identify and training was not on-site to enable staff to check this. The manager noted agency use was limited, and they tried to use the same agency staff for consistency.

Recruitment procedures were generally in line with requirements, however some staff did not have references to confirm they were of good character for their role. Few staff had received supervisions, but the manager was working to address this. Staff universally told us they felt supported and able to raise any issues with the new manager. A staff member stated, “The manager is approachable and so easy to talk to.”

People and staff mostly told us staffing numbers were safe and staff shared that staffing numbers had recently increased which had had been positive. The management team were working with the staff team to ensure effective deployment.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Whilst most staff had completed infection prevention and control training, our observations did not support that all staff understood how to promote good infection prevention and control practices. The provider’s checks had not consistently identified and addressed these. For example, we observed personal protective equipment (PPE) which had not been correctly disposed of and staff carrying used PPE in their hands. In the medicines room, staff did not have access to hand soap or paper towels to wash their hands before handling medicines and before or after removing PPE. Whilst some parts of the service were clean, other areas had not been cleaned to a high standard including the medicines room. Some of the equipment had not been properly maintained to ensure this could be effectively cleaned.

Most people and professionals however were positive about the overall cleanliness of the service. The manager intended to implement cleaning schedules to guide staff with routine and deep cleans of the service.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning. The provider’s systems and checks were minimal and failed to identify unsafe medicines practices which exposed people to the risk of harm. This included staff crushing medicines which they had previously been informed not to. Medicines records did not support that people were given their medicines in line with the prescriber’s instructions including for time specific medicines. For medicines to be administered as and when needed, protocols were not always in place to guide staff about when and how to administer these. Patch administration records also did not support these were applied in line with prescribing instructions. Staff failed to escalate missed medicines or medicines errors through the appropriate internal routes to ensure advice could be sought and incidents investigated. The provider had not ensured records of staff competency were in place for all staff administering medicines.

We shared our significant concerns about medicines practices with the provider and manager. They took immediate actions including a full audit of medicines, some staff were removed from administering medicines whilst training and competency was re-visited and all staff were to attend further medicines training.