24 August 2015
During an inspection looking at part of the service
Orchard House is registered to provide personal care for people over 55 years old in their own homes and within sheltered accommodation. The service provides rehabilitation and re-enablement care, within 18 individual on-site flats, as well as rapid response care for people in their own homes during the night. At the time of our inspection 15 of the flats were occupied.
The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
During our inspection on 2 February 2015, we found that the registered person did not have effective systems designed to enable them to regularly assess and monitor the quality of the services provided in the carrying on of the regulated activities. We found that the audit checks that had been completed were not always effective in identifying the issues that we found or detailing the action that needed to be taken to address them. This was a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014.
Following the inspection the provider sent us an action plan detailing the improvements they were going to make, and stating that improvements would be achieved by early August 2015.
This report only covers our findings in relation to the outstanding breaches of regulation. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Orchard House on our website at www.cqc.org.uk.
This follow up inspection took place on 24 August 2015 and was announced.
During this inspection, we found that improvements had been made to the audit systems in place within the service, to ensure that appropriate standards of record keeping and data management were in place, and overviewed and monitored on a regular basis. We found that the systems in place had been strengthened which meant that any issues could be identified and addressed in a timely manner.
While improvements had been made which means that the service is no longer in breach of regulations, we have not revised the rating for this key question. To improve the rating to ‘Good’ would require a longer term track record of consistent good practice. We will review our rating for well- led at the next comprehensive inspection.