Orchard House Care Centre

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• 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 assessed 4 quality statements within this key question and identified 2 breaches of the legal regulations. Some people’s care records contained inconsistent information or missing detail. This placed people at risk of harm as staff did not have reliable information on how to mitigate risks in people’s care. The provider was unable to supply all necessary information to demonstrate all required pre-employment checks had been completed to ensure safe recruitment practice. We received mixed views from people and relatives in relation to the staffing levels, with some people saying they needed to wait for support. The management team and staff understood their safeguarding responsibilities. Staff were able to identify, prevent and report incidents of abuse. The management team had taken appropriate action in relation to safeguarding concerns. At this inspection there was no evidence of closed cultures. Staff were able to raise issues and felt listened to and supported. Staff protected people's human rights in line with the Mental Capacity Act 2005 (MCA) and received training on this. We observed staff seeking people's consent before assisting them. Where people lacked the capacity to understand and consent to aspects of their care such as being administered medicines, a formal assessment under the MCA and subsequent best interest decision had been completed appropriately. The management team understood their responsibilities in terms of making applications for deprivation of liberty safeguards (DoLS) as required. There were systems in place for monitoring these and ensuring they were kept up to date. There was a proactive and positive culture of safety based on openness and honesty. There were robust processes in place to monitor incidents, accidents, and potential safeguarding events.

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.

People and relatives told us they knew how to complain should they need to and said they were confident action would be taken. All reported concerns and complaints were logged. Evidence demonstrated actions had been taken when concerns and complaints were received.

Staff described an open culture where learning was shared to improve safety and care. Staff confirmed they were involved in daily stand-up meetings, group supervisions, one-to-one and staff meetings to share information. They confirmed these included discussions about any concerns which had been raised or identified and actions to take to prevent reoccurrence. The management team described actions they had taken to support continued learning. These included, staff meetings and workshops, additional training, supervision, spot checks on staff practice, investigations of concerns and the analysis of incidents, accidents, complaints and safeguarding to help identify themes and trends.

There were robust processes in place to monitor incidents, accidents, and potential safeguarding events. Records demonstrated incidents and accidents were recorded, acted on and analysed. Monthly audits of all incidents and accidents were completed. This helped ensure any trends or themes identified could be addressed to help mitigate risk and prevent reoccurrence. Where required, action plans were developed to support ongoing improvements. The registered manager had a clear understanding of their duty of candour requirements. They were able to provide evidence which demonstrated that if people came to harm, relevant people would be informed in line with the duty of candour requirements.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and relatives told us they felt safe. Comments included, “There’s plenty of staff to keep an eye on you”, “[person’s] safe, yes” and, “They [staff] hoist me, its fine.”

Staff and leaders assured us they understood safeguarding processes and how to protect people’s rights. Staff confirmed they had received safeguarding training and demonstrated they knew how to prevent, identify and report allegations of abuse. Staff were able to describe the actions they would take if they witnessed or suspected abuse may have occurred. They were confident the management team would take appropriate action if concerns were raised. The registered manager was aware of their role and responsibilities to safeguard people from harm and abuse.

We observed people appeared relaxed and comfortable throughout the inspection. No safeguarding concerns were observed.

Appropriate systems were in place and followed, which protected people from the risk of abuse. The management team understood the actions required should they identify a safeguarding concern. Where these had occurred, they had been reported appropriately to the local safeguarding team and CQC. The management team understood when an application to deprive someone of their liberty should be made and appropriate applications had been made where required. There was a system in place to ensure these were renewed appropriately.

People and relatives told us they felt safe, but did raise concerns over the attention to personal care needs, specifically oral hygiene and nail care. A relative told us, “I noticed [Name’s] breath was smelling. I asked them to brush [their] teeth.”

Staff were able to describe how individual risks such as epilepsy and diabetes were managed. However, in practice, staff and leaders were not always taking appropriate action to ensure people's safety through responding to needs or ensuring appropriate care plans were in place. Staff told us they had access to appropriate equipment. Based on feedback from leaders, we were not assured that there was robust oversight of the quality of care and management of risk to ensure a consistent standard of care.

Staff did not always respond to potential risks in a timely way. Throughout the inspection, we observed periods where staff did not appear available to respond to people’s needs in a timely way. For example, we heard one person calling repeatedly from their bedroom. Although at times staff were in the area, they did not go into the person’s room to provide them with support or check their safety. We met another person outside their bedroom leaning on their door and holding their walking stick. The person appeared unsafe and unsteady on their feet and we supported them to return to their room to sit down. There were no staff visible, and we noted a falls alert mat indicating they were at risk of falling. Whilst equipment was generally used to support people’s safety, we observed one person had their bedrail in a raised position. Their care plan clearly stated this should be left down as there was a known risk of the person climbing and falling over the rail. However, we observed people were supported safely when assisted with equipment, such as hoists and wheelchairs. When staff supported people to walk with the use of walking aids this was done in a safe and unhurried way.

Information for staff on how to mitigate risks in people’s care was not always clearly or consistently recorded. This placed people at risk of harm and was a breach of Regulation 17, Good governance. We reviewed 9 people’s care records and identified some contained inconsistent information or lacked detail. Two people, admitted on a ‘discharge to assess’ potentially short-term arrangement from hospital, had minimal assessments, risk assessments or care plans in place. Not all information had been transferred from partner reports placing people at risk of not having risks identified or managed. For another person, we noted their choking risk assessment and care plan detailed different food textures. This meant the person was at risk of receiving food at an inappropriate consistency placing them at risk of choking. For other people with specific health needs such as diabetes, clear guidance was not always recorded in their care records detailing how to identify and mitigate risk and how their condition should be managed. The shortfalls in care planning and risk assessment had not been identified in the reviews conducted by the service. Whilst staff had a good understanding of people’s individual needs, the lack of clear records placed people at risk of inconsistent or inappropriate care and treatment. We discussed our concerns with the registered manager and a nurse who agreed more detail was needed to ensure staff had clear information to manage risk. However, we noted positive examples of issues being highlighted by the management team through their quality assurance processes. For example, audits of food and fluid charts identified the completion of these was not always robust. This had been brought to the attention of staff and actions had been taken to address this. The registered manager showed us how they monitored staff practices to ensure safe care was provided. These included, staff observations, supervisions and gathering regular feedback from people.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We received mixed views from people and relatives in relation to staffing levels in the service. A person told us, “There’s plenty of staff. They come more or less when you need them, unless there’s an emergency.” Another person said, “If you need someone, you can get someone.” However, other comments included, "They [staff] don’t come quickly. Sometimes I wait a long time. It’s everyday life, you’ve just got to fit in with them. There’s not enough staff.” “At weekends it’s difficult to get anyone. I thought it was because they didn’t like me, but it’s generally like that. I have to wait for them to take me to the toilet. They say you’ve got to wait, but sometimes you can’t wait", and "I don’t bother ringing now, I go and find someone. At certain times of the day it’s like the Marie Celeste. The weekends are very quiet." The comments from people and relatives were discussed with the registered manager on day 2 of the inspection who agreed to investigate this. People had confidence in the staff and their skills. One person said, “I enjoy it in here staff trained up well.”

Staff were positive about the staffing levels in the home, felt supported in their roles and received one-to-one sessions of supervision and regular training. Staffing levels were discussed with the registered manager who confirmed staffing levels were determined by the number of people using the service and the level of care they required. The registered manager kept staffing levels under review and used a formal assessment tool to determine the numbers of staff required to meet people's needs. Call bell audits were frequently completed to verify staffing levels remained sufficient, and people's needs were met in a timely way. Staffing levels were also discussed daily during the ‘stand up’ meeting to ensure there were appropriate levels of staff throughout the home. If shortfalls were noted on particular units at this meeting, staff allocation would be reconsidered. Staff told us they had received appropriate training and felt confident in their roles. However, while the registered manager was aware of the pre-employment checks required, they confirmed they were not aware of the issues we identified. They undertook to address these shortfalls.

At times during our assessment, we observed periods where staff did not always appear available to respond to people’s needs in a timely way. We noted within the units on the ground floor a number of people were cared for in bed and interactions between people and staff were limited and mainly task focused. However, observations within the memory unit were positive with lots of staff engagement with people.

We checked the recruitment records of three staff and could not be assured all the required pre-employment checks had been effectively completed to ensure only suitable staff were employed. Within 2 recruitment files there where long gaps in employment which had not been identified or investigated by the service. Additionally assurances in relation to past employment in care had not always been obtained in line with Schedule 3. This was a breach of Regulation 19, Fit and proper persons employed. Processes were in place to monitor staffing levels. These included call bell audits, staffing level dependency tools, staffing audits and systems to gather feedback from people and staff in relation to staffing. We also saw evidence that actions had been taken to address staff shortfalls were required. Audits conducted by the service had not indicated concerns in relation to the staffing level within the home. Staff were provided with appropriate training to help ensure they had the skills to care for the people they supported. Review of the training matrix demonstrated appropriate training was provided in a timely way.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.