Orchard House Care Centre

“We found that the provider was in breach of the regulations relating to person centred care, dignity and respect, consent, safe care and treatment, safeguarding, good governance and staffing. The provider was no longer in breach of regulation in relation to fit and proper persons employed. We discussed the concerns found during our inspection with the management team and we raised concerns to the local authority.”

“Care was not consistently tailored to individuals’ needs, preferences, or risks. Care plans were incomplete or not followed in practice. Staff did not consistently apply an appropriate approach to support people’s frustration, anxiety or confusion, and interactions sometimes escalated distress in people living with dementia.”

“People’s dignity and comfort were not always maintained, and staff did not consistently respect people’s rights to make decisions about their care. Environmental risks, infection prevention controls, medicines management, nutrition, hydration, and skin integrity practices were inconsistent, increasing the risk of harm. Clinical observations were delayed or missed, and care interventions did not reliably mitigate identified risks.”

“Staff did not always respond promptly to people’s immediate needs or escalate safeguarding concerns appropriately. Call bells were sometimes out of reach, and people living with cognitive impairment were observed unsupervised or in unsafe conditions, placing them at risk of harm.”

“Staffing levels, skill mix, supervision, and support were inconsistent, limiting staff capacity to deliver safe and person-centred care. Workforce wellbeing was not consistently promoted.”

“Oversight, audits, and quality assurance systems were ineffective. Repeated gaps in care planning, risk management, staffing, and personal care had not been addressed since previous inspections. Communication between staff was fragmented, and serious incidents were not consistently reviewed or used to improve practice.”

“We have asked the provider for an action plan in response to the concerns identified at this assessment relating to person-centred care, dignity and respect, consent to care and treatment, and staffing.”

“In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.”