We undertook a comprehensive unannounced inspection of Orchard House on 23 January 2019. Orchard House is a ‘care home’ registered to provide accommodation and support. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Orchard House is a neurological rehabilitation centre providing specialist community-based transitional rehabilitation for people with brain and spinal injuries, stroke, minimally conscious states and a range of progressive neurological conditions. The service could support up to nine people in one adapted building with communal areas and eight bedrooms. In addition, there is a self-contained flat for those in active rehabilitation to support their move on to more independent living. There were eight people living at Orchard House on the day of the inspection.

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.

At our last inspection we rated the service Good overall. At this inspection we found areas of the service had improved to Outstanding.

The leadership and management of Orchard House had made significant improvements since the last inspection. This was evidenced by high levels of satisfaction from people, relatives, staff and professionals. The registered manager had aspired to achieve a service that delivered exceptional care and support people in the service. The registered manager had continually thought of initiatives to make improvements to enhance people’s lives and those of the staff. The vision and values of the service were reflected in day to day practice and staff demonstrated the values, clearly showing a very person-centred service. The impact of this meant people felt valued and cared for and their feedback reflected this. The registered manager had sought to improve not only their own learning but provided opportunities for staff to develop and learn as well. This was reflected by staff comments about the manager and their effectiveness and how well supported they felt by the manager.

The effectiveness of the service had improved to Outstanding. The service had received re-accreditation with three domains rated excellent from a national organisation that specialised in promoting understanding in all aspects of head injury. Staff were trained to follow best practice and training in this specialist area and specific training was developed to enhance staff’s understanding of people’s conditions. Staff were provided with excellent support from their manager which meant staff could go on and support people well. The importance of food and fluids had been considered to ensure these provided choice and were palatable and enjoyable. Any risks associated with eating had been assessed and were managed in line with taking positive risks.

People’s needs were assessed in all areas of their life and information had been sought to inform people’s ongoing care. Current national guidance and advice was used to improve people’s health and social care. When people moved to the service they were well supported and at the time of discharge, arrangements were well organised to ensure the person had adequate ongoing facilities in place to meet their needs. People’s health was optimised with input from relevant professionals and relevant information recorded to inform other health services to ease communication. Where necessary, technology had been considered and put into place to enhance people’s outcomes. People were supported to have maximum choice and control of their lives and staff supported them in the least r

This inspection took place on the 20 June 2016 and was an unannounced inspection. At our last inspection in July 2015 we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to the safety of the premises, safe and proper management of medicines and infection control. The service was not doing everything reasonably practicable to make sure people who used the service received person-centred care to meet their needs and reflect their personal preferences. The service had not carried out regular audits, risks had not been identified and records in respect of consent were not accurate. There was no reference in the records about discussions with people or their carers. Staff had not received the relevant training to carry out their roles and responsibilities.

We told the provider to take action and they sent an action plan detailing the actions they would take to improve. During this inspection we found improvements had been made.

Orchard House is registered to provide accommodation and personal care for up to nine adults with acquired brain injury, stroke and other neurological conditions. They provide rehabilitation services within a community setting. At the time of our inspection the service had seven residents.

There was a registered manager in post. 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.

People told us they felt safe. Staff had received regular training to make sure they maintained their knowledge in relation to recognising and reporting safety concerns. People received their medicines as prescribed. Staff carried out appropriate checks before administering medicines. Records were accurately maintained and all medicines were stored safely and securely. Where risks to people had been identified risk assessments were in place and action had been taken to reduce the risks. Staff were aware of people’s needs and followed guidance to keep them safe.

People were supported by staff that had the knowledge and skills to effectively care for them. Staff had received the training and support they required to ensure people received good care. The registered manager and staff were aware of their responsibilities under the Mental Capacity Act 2005 (MCA) which governs decision-making on behalf of adults who may not be able to make particular decisions themselves. People’s capacity to make decisions was regularly assessed.

People were provided with food and drink that was freshly prepared and presented nicely. People we spoke with told us they enjoyed the food and had choices about what they ate.

People spoke highly of the care they received. Staff understood the needs of people and provided care with kindness and compassion. Staff spent time with people and treated people with dignity and respect.

People’s care was planned ensuring that people were treated as individuals. People had been involved in developing their care plans and reviewing these. People were encouraged to be involved in activities and to take part in activities that assisted their rehabilitation, such as swimming and physiotherapy.

People in the service knew the registered manager and spoke to them openly and with confidence. The service had systems to assess the quality of the service provided in the home. These systems ensured people were protected against the risks of unsafe or inappropriate care. All staff spoke positively about the support they received from the registered manager. Staff told us they were approachable and supportive. The service worked with other professionals to ensure people in the service received the optimal input in their rehabilitation.

We inspected the service on 9 and 14 July and 11 August 2015. This was an unannounced inspection and the first for the service since registration.

Orchard House is registered to provide accommodation and personal care for up to nine adults with acquired brain injury, stroke and other neurological conditions. It provides rehabilitation services within a community setting. At the time of inspection five people were using the service and one person was staying at the service on respite for two weeks.

The registered manager had left the service shortly before the inspection. 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. A manager was due to begin working at the service the week after our inspection. In the absence of a manager, the service was managed by the Deputy Manager and the Group Operations Director.

There were not enough staff to meet people’s needs or to keep them safe. People told us there were not enough staff to meet their needs and the rotas showed that target levels of staff had not always been achieved. Although preferred activities for residents in the service were stated on their care plans, staffing levels meant these activities often did not take place.

People were not always cared for by staff who had kept up to date with current best practice because not all staff had attended training or received adequate supervision and appraisal.

Some staff understood their responsibilities under the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS); these provide legal safeguards for people who may be unable to make their own decisions. However, staff knowledge in this area required improvement.

The service was not following legislation and guidance in respect of consent to care and treatment in line with the Mental Capacity Act 2005.

The service did not have effective systems in place to ensure infection control was adequately monitored and managed.

Some records in relation to medication were not always accurate and so people did not always receive their medicines in line with their prescription.

The service did not have an effective system which allowed them to identify where improvements were needed.

People told us they enjoyed the meals and we saw there was a choice of meals. Observations at the mealtime showed good interaction and appropriate support provided.

The service had a system in place for dealing with people’s concerns and complaints and had followed these.

People’s privacy and dignity was maintained during care tasks. People were assessed regularly and care plans were detailed. A range of other professionals were involved in people’s care to ensure their needs were met but people who use the service were not always involved in decisions around their care.

People felt safe and told us they liked living at the home. People who used the service and their relatives were complimentary about the staff and felt staff did their best to support them in a friendly and caring way.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we took and what action we told the provider to take at the back of the full version of the report.