Orchard Views Residential Home

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• 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

During our assessment of this key question, we found concerns around the governance and leadership of the service. This resulted in a breach of Regulation 17 Good Governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found the provider did not have sufficient oversight to ensure there was effective leadership in place or to ensure that care was delivered safely and in line with planned care. Where incidents had occurred, the provider had failed to take action or implement lessons learned. Slight progress had been made in some areas at our second visit, but we still found people insufficient action had been taken to mitigate risks and ensure safe support. This placed people at risk of significant harm.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff shared concerns about leadership in the service and issues with the staff group that made working as a team difficult. They told us that although they felt they could approach the senior team they were not confident that their concerns would be acted upon.

The provider had failed to ensure that there was a positive culture in the home that was open, transparent and person centred. Recurrent changes within the management team and a lack of clear leadership had contributed to an unsettled and unhappy staff team.

The service did not have a registered manager and was recruiting to this role. We were informed that changes in management at the service had impacted on the running and oversight of the service with a number of audits not being completed. The provider was asked to ensure interim leadership was in place whilst a new manager was recruited and induction completed.

The poor culture in the home and potential impact on care delivery was not identified by the provider due to a lack of clear leadership and oversight. Ongoing instability within the management team had created a culture at the service that was not inclusive with staff and relatives raising concerns with us about leadership of the service.

Staff told us they did feel comfortable approaching managers however they did not feel that their concerns or suggestions were listened to or acted upon. One staff told us, “Management are approachable, but you go to them with issues, and nothing gets done.”

The processes in place to support staff to raise concerns had not ensured that staff felt listened to or that concerns or suggestions raised had been considered and acted upon. Feedback was not actively sought, or action taken to ensure staff felt their voice would be heard. Staff were not receiving supervision at the frequency identified by the provider’s policy.

Staff told us they did not work well as a team, did not feel listened to and were frustrated with changes and high agency use. One staff told us, “I think we need more regular staff as agency are causing a lot of concerns. But we can’t keep regular staff as they all start and then realise how tough the job is and then leave.”

The processes in place at the service had failed to ensure that staff feedback was used effectively or that action was taken to ensure staff felt valued.

Staff were not always fully aware of their roles and responsibilities and told us they didn’t feel listened to or involved in decisions about the service. We were informed that some audits had not been completed due to changes in management and issues that had occurred within the service which had affected capacity.

The provider failed to ensure that effective governance and audit systems were being completed. We identified concerns at both visits in medicines management and assessing and monitoring risks to people’s safety. Audits that were undertaken had failed to identify all concerns we identified, or action taken to mitigate current or ongoing risks to people. There was a lack of effective leadership in place to ensure the delivery of good quality care, and support. There was a lack of robust and effective quality monitoring and assurance processes to identify issues and provide service level oversight. Lessons learned from incidents that had occurred were not being completed. This presented a potential risk to people and increased risk of harm. The senior team were not fully aware of their responsibility to inform the CQC or other partners about notifiable incidents and therefore notifications including safeguardings had not always been submitted as required.

Relatives we spoke to told us that they received communication from the service about general updates but did not recall recent involvement with resident or relative meetings, requests for feedback or formal involvement in care planning or future planning. One relative told us, “There are no relative’s meetings or a newsletter that I know about. Nobody has ever asked me for feedback about [Name’s] care.” Another commented, “I wouldn’t say there was a free flow of information. They haven’t asked me what I think.”

The senior team informed us they were working with the Local Authority to address concerns that had been identified. However, we found that limited progress had been made and concerns were ongoing. Staff were feeling frustrated and felt the service lacked clear leadership and direction. They also felt they were not involved or included in any decisions about the running of the service.

At the time of our first visit the service had been placed in organisational safeguarding by the local authority and a hold placed on any new admissions. This was later escalated by the local authority to a withdrawal of the contract and people they funded supported to alternative placements as a result of continuing concerns. We completed a further visit following further concerns highlighted to us by the local authority. We received limited feedback from professionals involved but those we spoke to overall were positive about the staff team but felt that communication within the service could be improved.

We found that care records in place were not always up to date, accurate or sufficiently detailed. Therefore, when information about people needed to be shared between services there was no assurance of the quality of information shared. On our second visit we received information from the local authority that where people had been supported to alternative placements significant concerns had been reported by staff at the homes, they had moved to around medicines management, care planning, oversight of health conditions and personal care. A number of safeguarding notifications had been raised in relation to these concerns.

Staff did not feel consulted or involved in how the service was run or could be improved. They had concerns regarding the leadership in place and the ability of leaders to address issues raised. Staff told us they lacked clear guidance and direction. One staff commented, “It’s just not being run right.”

The leadership team were not proactive in using information from audits, complaints, incidents, and safeguarding alerts to improve the service. They were not working with staff to understand how things went wrong and involve them in finding solutions. The provider had not ensured that incidents were investigated, and lessons learned completed. The risks to people were not mitigated and people were placed at risk of significant harm. Action was required to ensure good leadership and effective systems were in place to drive learning and improvement at the home.