Orchard Court

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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’s vision, strategy and culture were not always embedded in practice, as further work was required to ensure these were consistently implemented. Although the provider had a shared vision based on transparency, equity, inclusion and engagement, this was not yet fully reflected in people’s experiences at the time of the assessment.

Leaders had not maintained sufficient oversight or established systems to ensure the safety and quality of the service which was not consistent with the expectations of capable, compassionate and inclusive leadership. However, leaders understood the context in which they delivered care and support and demonstrated openness and honesty in their approach.

The provider records did not demonstrate regular checks had been undertaken at the service and did not always capture all required actions. This did not support the development and safety of the service. Further provider level checks commenced during the assessment and there was a clear drive to improve these.

The manager had only been in post for a short time and had submitted their application to register with CQC. People, their relatives and staff spoke positively about their manner describing them as visible and approachable. Comments from staff included, “The manager is doing an amazing job; they are really, really good” and "They’re great, I can raise any issues with them." Staff appreciated their ‘hands-on’ approach. Further work was required to support their ongoing development within this role.

People who used the service and their relatives mostly told us they felt the service was well-run but acknowledged there were areas for development.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. A whistleblowing policy was in place and staff felt confident they could raise any concerns. A staff member stated, "I wouldn't hesitate to report. [Manager] is on it.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider took actions to address issues as they arose, and staff felt supported in their role.

The provider had not established or operated effective systems of governance. The had led to issues which could have compromised the safety of people using the service, including concerns around medicines administration. The provider’s systems and checks of medicines were not robust and had failed to highlight gaps in staff knowledge and practice.

The provider did not consistently record the checks completed at the service and use them to drive improvements. Contemporaneous records for staff training, competency checks and people’s care records were not always in place. The provider did not promote best practice in how people’s capacity was assessed and the associated decisions made on people’s behalf. Furthermore, premises and equipment audits had failed to identify some of the shortfalls including concerns around fire safety and maintenance of the environment. Further work was required to capture people’s views and use this in the development of the service.

During the assessment, some immediate remedial actions were taken to address some of the environmental concerns. The provider also initiated targeted audits in areas such as care planning and recruitment. A comprehensive audit was also undertaken of medicines with further training arranged and staff competency to be assessed.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Visitors were encouraged to maintain contact with people who used the service. The manager was considering ways to further develop their integration within the community, such as looking to introduce church services. The staff partnered with health and social care services in their support of people.

The provider did not always focus on continuous learning, innovation and improvement across the organisation. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The provider’s quality assurance processes were not implemented effectively and did not identify the shortfalls found during this assessment. Accidents and incidents had not considered learning points to mitigate risks to people’s safety and improve practice within the service. People who used the service and their relatives had not been involved in the development of the service. Further work was required to utilise sources around best practice and implement these within the running of the service.

The manager shared they recently started meeting with managers from the other services within the provider’s group with the aim of sharing good practice and strengthening the development of the service. The nominated individual noted the actions they were taken, including new staff appointments, to develop the service.