Orchard Views Residential Home

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

We found that people were not always protected from abuse or improper treatment. Systems for the management of medicines were not effective and where people had risks which could impact their health and wellbeing these were not always assessed. Where risks had been identified action taken to mitigate risks was not always taken. Care records were not always clear or robust in identifying support needs or mitigating risk and people were not always receiving planned care. Staff were not always recruited safely with appropriate references not always sought and gaps in employment not always explored. Staff received training relevant to their role. However, a review of training provided across all roles was required to ensure staff had the skills and competence to support people safely. There were sufficient staff at the service, however we found that staff did not always follow direction and could be better deployed at key times throughout the day to ensure consistent and safe support was provided. Audits were not always completed and the monitoring systems that were in place did not provide adequate oversight of the service. This meant some aspects of the service were not always safe and there was an increased risk that people could be harmed. This was a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Although we found some actions had been taken at our second visit, we found insufficient progress with some significant concerns from our last visit still in process or not yet actioned. Systems and processes to ensure good governance were still failing to identify and manage risks to people.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received feedback from some relatives that they were unsure whether appropriate action had been taken when incidents had happened or when they had raised concerns for their relative. One relative told us, “Since being bedridden, I have had to ask the carers half a dozen times to please reposition [person] as they were in the most awkward positions. They do come quickly when you ask, but why do I have to ask?” Another told us, “I have often found [Name] in a wheelchair when I visit. It is usually the afternoon and [person] is still in the wheelchair from lunch. I ask them to put [person] in a comfortable armchair and they do it quite quickly.” Our assessment found elements of care did not meet the expected standards.

Staff members told us they felt able to report concerns but were not confident in concerns always being acted upon. One staff member told us, “I’ve raised medication errors for the past few months with no follow up.”

There had been several changes in the management team, and we were informed no recent audits had taken place. The senior team informed us they were in the process of responding to the concerns raised by the local authority. This meant that there was no management oversight of risk or care delivery to ensure people were receiving support in line with their planned care. Where incidents had occurred, the provider was not completing an analysis of accidents or incidents or implementing lessons learned. People were therefore placed at increased risk of harm as future risks had not been mitigated for them or others living at the home. The system for notifying external parties also needed review as not all notifiable incidents had been referred as required.

We received mixed feedback from relatives on their involvement in the assessment and care planning process. One relative told us, “They did ask a lot of questions about [Name] when they first went in there, so they do seem interested in [name] as a person. Such a lot has changed in the 2 years [person] has been there though.” Another commented, “We haven’t had any real conversations about [Name] and their likes/dislikes.” People were not experiencing continuity of care We found that care plans were not always up to date, or accurate and planned care not always completed. Our assessment found elements of care did not meet the expected standards.

Staff we spoke to felt that communication was poor including information shared at handovers. One staff told us, “A handover shouldn’t be based on one night. Should be based more on a full picture.”

We received mixed feedback from partners. Professionals who were present at the time of our first visit were complimentary of the staff team but did comment on concerns about the sharing of information. One told us, “Feel like there aren’t enough staff on the ground and when swapping over I don’t feel they know what’s going on.” At the time of our first visit the service was in organisational safeguarding and had an embargo in place. We had received concerns from the local authority about the home including incidents not being reported. On our second visit the local authority had withdrawn the contract with the home and was in the process of moving people they funded to alternative placements due to ongoing concerns.

Assessments were completed before admission and staff gathered information about people's needs prior to them receiving support. However, this information did not always transfer into people’s care records to provide staff with detailed, accurate and up to date information. Important information for example people’s dietary needs was not effectively shared within the service, and during the inspection we observed people not receiving care in accordance with their plans. Referrals to health professionals were also not always completed in line with people’s needs. This placed people at risk of harm.

We received mixed feedback from relatives who raised concerns around areas including nutrition, falls, personal care, and medication. One relative told us, “I’m not 100% sure [person] is being bathed properly as we have noticed recently that [person’s] skin has become very dry and flaky.” Another relative commented, “When I have asked, [Name of relative] has told me that there are not many staff on at night and they don’t do much for people. If they (residents) say no, to something, they don’t bother (any further).”

Staff received training in safeguarding people and whistleblowing. However, we identified people were not always supported appropriately and risks were not always managed effectively. We were not fully assured staff had the knowledge or information to provide safe support, which could mean people’s needs not being met and possible neglect. Staff raised concerns with us about the quality of some training and lack of communication particularly around handovers of essential information.

We could not be confident people were safeguarded from abuse and avoidable harm. Risks to people were not always being managed safely. This placed people at increased risk of harm. During the inspection visit we observed people being supported in ways that were not in line with their planned care. People’s risk around choking and weight loss were not being managed effectively and appropriate systems were not in place to ensure people with or at risk of pressure areas had regular pressure care regimes in place. We noticed that some staff failed to follow requests from senior staff resulting in people receiving delayed support. This had the potential to impact on people’s physical and emotional wellbeing.

The provider did not have effective oversight to identify and manage risks in relation to safeguarding people from abuse and improper treatment. People’s care records and risk assessments did not always accurately reflect their needs or provide enough detail how the service was working within the principles of the mental capacity act. People were not always receiving their medication as prescribed. Food charts were not being completed consistently for people at risk of weight loss and there was a lack of clear and accurate information on how food should be prepared for those people at risk of choking. Appropriate measures were not in place to ensure people had regular and appropriate pressure care regimes in place to reduce their risk of pressure sores or contribute to the healing or recovery of pressure areas. This place people at significant risk of harm. Staff had completed safeguarding training and the provider’s safeguarding policy guided staff about different types of abuse and how to raise a concern to ensure people were protected. However, records showed staff had not always followed guidance for recording, reporting, and managing incidents and accidents. Some events were not reported as required to either the Local Authority or CQC.

Risks to people were not always safely managed. Overall relatives felt their family member’s risks could be better managed. “One relative told us, “[Name] is supposed to be checked every 2 hours. It says its being done but [person] always seems to be in the same position (in bed). It’s concerning.”

Some staff were not always aware of people’s individual risks and how these were managed and information available was not always detailed or accurate. Staff felt the systems to share information where people’s needs had changed could be improved. There was a failure by the provider and senior team to ensure all risks to people were considered or shared effectively. This placed people at increased risk of potential harm.

During our site visits we observed some practices which did not always promote people's safety. We also observed inconsistencies in information that was recorded, for example nutritional information in people’s plans was not always accurate or available and information in food preparation and serving areas was not available on our first visit and on our second visit was still missing information for one person regarding their risk of choking. This placed people at risk of avoidable harm. Concerns were fed-back to the senior team and actions to address these specific concerns was taken.

People were at risk of harm as the provider had not always identified, mitigated, or safely managed risks to people. Where risks to people were known, risk assessments and care plans were not always up to date, detailed or accurate. For example, the care plan for one person did not include information relating to a specific health condition. Some people had conflicting information within their care records, which also put them at risk of not being supported safely. For example, there was conflicting information in some care records relating to how often a person with a pressure area should be repositioned. Records of support carried out were not always recorded. For example, where a person required regular repositioning to aid pressure areas or checks on their wellbeing there were gaps in the records of support provided that were not being identified by checks or audits. It was therefore unclear whether support had been provided at the required frequency. We found people at risk of weight loss were placed on food charts, but these had not always been completed properly. Therefore, it was unclear whether the people were receiving adequate nutrition or supported appropriately. Audits were not always being completed or where in place they were not effective. The provider failed to have sufficient oversight of the service.

Overall people and their relatives raised no concerns regarding the environment. One person mentioned that it could be cold at night. One relative commented, “They recognised that [Name] would be better in a larger room as [person] is tall, so they moved [person] when one became free. [Person] appreciated that.” Another said, “[Name’s] room could certainly do with a lick of paint, as could some other areas of the Home. It seems quite clean at least.” Our assessment found elements of the environment did not meet the expected standards.

The provider had a refurbishment plan for the building with redecoration of communal areas in progress during our visit. While staff raised no concerns our assessment, we found that some elements of the environment did not meet the expected standards.

We observed items stored by a fire exit which posed a risk to people in the event of a fire. This was actioned immediately. Some areas of the building were tired and dated and in need of decoration. The communal areas were being decorated at the time of our first visit and the provider confirmed that the plan was to decorate all areas. Some storage areas were untidy, and some areas including the kitchen required a deeper clean. We noticed some broken furniture present in some people’s rooms which we asked to be removed and replaced.

There were systems in place to monitor and improve the safety and upkeep of the premises. However, some issues we noted during our visit had not been picked up by the audits in place and improvement was needed.

We received mixed views from people and relatives about staffing levels,staff competency and agency usage. One relative commented, “I think the regular staff do their best, but I am not sure they are trained in dealing with advanced dementia. There doesn’t seem to be much stimulation.” Another told us, “Generally, there seems to be a very high turnover of staff, and I think the employed ones (as opposed to agency) seem to struggle with that.”

Some staff we spoke to felt there was a negative culture in the home and conflict between some team members which could impact on residents. Staff told us they didn’t always feel supported and that although they felt able to raise issues, they were not confident that they would always be acted upon. Some staff told us they felt overwhelmed and had concerns about agency usage. Some staff did not feel that training provided was of good enough quality to equip them with the skills to support people effectively and that guidance could be improved. One commented, “We need more clarity and training and for everyone to be on the same page.”

There were occasions when people were seen waiting for support for long periods and limited checks being completed on people in their rooms. We noted that one staff on our first visit failed to respond to a person when asked by a senior member of staff to provide immediate support. This placed people's health, safety and wellbeing at risk. During our visit we did see some nice interactions, but staff were often busy with care tasks and many of the interactions we observed were task orientated. Staff had very few opportunities to spend any meaningful time with people and we saw no activities taking place across both visits.

The senior team at the service were aware of incidents that had taken place involving unsafe care delivery. However, insufficient action had been taken to mitigate future incidences. This placed people at risk of avoidable harm. At our second visit we found risks identified at our first visit were still not being effectively managed or sufficient action taken. There was a notable culture within the home with some staff failing to work positively with the senior team or others and some staff feeling not listened to. We found staffing levels were sufficient to meet people's needs. However, at the time of our visit we noted staff were not always suitably deployed to provide appropriate levels of support and maintain the safety and wellbeing of residents. Processes were in place to monitor staff training and competence however the training was not always effective in enabling staff to be competent in providing appropriate care. Records provided showed evidence of supervision taking place and observations to help staff to develop within their role. However, supervisions were not currently in line with the frequency identified by the provider’s policy. Recruitment procedures were in place. However, appropriate references were not always sought or gaps in employment followed up for all staff. Further work was also needed to renew monitor and track renewal dates of Disclosure and Barring Service (DBS) checks for staff.

Overall feedback from people and relatives did not highlight any concerns about cleanliness and hygiene at the service or how staff minimised the risk of infection. However, some concerns were raised regarding personal care. One relative mentioned that their relatives’ nails were not always clean, and another felt that their relative’s hair was often greasy.

We did not receive any concerns from staff about the management of infection within the service. However, we found that some elements of the infection control did not meet the expected standards.

Although there were improvements works underway including decoration, we still found some areas of concern. Some areas including the kitchen required a deeper clean and some areas such as sluices were poorly maintained making cleaning difficult, and one commode had not been effectively cleaned. At our second visit work was in progress to address the sluice but storage of laundry bags in that area increased the risk of cross contamination and the kitchen still required a thorough clean. Storerooms were cluttered and untidy. Laundry was not being managed effectively with different bag types of dirty laundry piled together in the laundry area on our first visit. This increased the risk of cross infection. PPE stations noted throughout the building. However, We observed that PPE (Personal Protective Equipment) was not always being used appropriately on our second visit.

An infection control policy was in place and staff had received training in infection control. However, current guidance on storage of dirty laundry was not always followed. This meant the risk of cross contamination was increased. The systems in place to monitor infection, prevention and control practice were not fully robust and did not ensure people were always protected from the risk of infection. However, a refurbishment plan was in place to address some of the maintenance and redecoration issues.

People were not always given their medicines as prescribed. People and relatives raised concerns regarding the administration of medication. One relative told us, “[Person] had seemed settled until about 2 months ago when it was discovered agency staff were not giving [person] their [Name of medicine].” Another commented, “[Name] tells me they have been giving [person’s] medication late some days, but I haven’t heard [person] say they have forgotten it altogether.”

Staff told us that medicines training, support and guidance was very basic and not sufficient to provide them with the skills to manage medicines safely.

Medicines were not always managed safely. This placed people at significant risk of harm. People were not always receiving their medicines as prescribed. There was failure to follow the policy in place and national guidance where people had not received their medicines including appropriate follow up with health professionals. The system in place to ensure medicines were always stored safely was not being followed. People’s PRN ('when required') protocols were sometimes not available or required further guidance. When some PRN medicines were administered the effectiveness was not always recorded or monitored. Where people were prescribed creams or patches body charts were not always in place to assist staff to know where to apply or to record rotation in accordance with the manufacturers’ directions. Appropriate guidance from a pharmacist had not been sought where people had their medicines administered covertly to ensure the method chosen such as mixing with tea was suitable for the medication prescribed and did not impact on its effectiveness. We found that handwritten MARs in place did not always have the required signatures in place or details of dosage. This placed people at risk of harm should the dose be transcribed incorrectly. Records of administration of topical medicines were not in place. It was therefore not clear whether these had been administered and people were at risk of harm from not receiving their topical medicines consistently. The provider had failed to ensure that training provided was comprehensive or robustly checked the competency of all staff who administered medicines. The audits in place did not cover all areas of medicines administration so were not able to pick up all potential issues. The last audit completed did not identify any of the issues found on our visit. Some improvements were noted at our second visit. However, we found insufficient progress had been made to ensure medicines were managed effectively.