The Orchards

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 good. At this assessment the rating has changed to 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 good governance.

This service scored 62 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The values of the service were shared with the staff. Training and support was provided to enable staff to work towards these values. Staff told us they felt happy and supported working at the service.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, and support and embodied the culture and values of their workforce and organisation. Leaders were visible within the service and led by example. A person told us, “I am well cared for here, much better than at home because they have all the facilities I need here.”

The registered manager as planned left during this assessment. Whilst a new manager had been recruited, as the assessment progressed there was no registered manager in post. To provide interim cover for the service a senior manager oversaw the day to day running of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff had access to supervisions where they could discuss their role and any suggestions or concerns, they may have. Staff spoken with told us they were able to raise any concern to leaders. A staff member confirmed, “Management are always approachable, (their) door is always open.”

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. A staff member explained how the senior management team had supported them personally. They said, “They support my well-being.”

The provider had governance systems to monitor and improve quality; however, these were not always effective. For example, specific monthly audits, mock inspections and external audits took place, but these had not always identified the concerns found during this assessment. Furthermore, where the provider’s governance checks did identify shortfalls, action was not always taken to ensure improvements were made, embedded and sustained.

During this assessment we found people’s care plans and risk assessments were not always accurate, and key information was missing around people’s known risks. Monitoring of the service provided had not identified that staff did not always follow people’s care plans around the safe and effective management of diabetes. Senior leaders told us where shortfalls were identified during audits, actions were placed on the service’s quality improvement plan. However, we found this did not always happen and this meant we could not be confident risks were always appropriately identified and acted upon.

Monthly governance checks did not always include a review of the previous audit undertaken, which meant effective monitoring of shortfalls and actions did not take place to drive and sustain improvements. Some audit tools used by staff were completed using a scoring system, or yes/no approach, but lacked information to detail why specific scores or answers had been selected. We found increased risk was present for people due to insufficient detail in audits, and actions were not always monitored and followed up effectively.Examples around this evidence were fed back during this assessment and the senior management team responded positively to this feedback.

Leaders and the staff team 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. Referrals had been made to external health and social care professionals when specialist services and guidance was required to promote people’s well-being.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. However, not all improvement actions were clearly recorded and acted upon to ensure these improvements were embedded and sustained.

Shortfalls found during this assessment were feedback and the provider responded positively to this feedback and told us how they intended to make the improvements needed. However, it is too soon to ensure these improvements are fully embedded.