About the service: Orchid Lawns is a residential care home providing accommodation for older people, who may be living with dementia, a physical disability or mental health needs, who require nursing or personal care.

People’s experience of using this service: People and their relatives were positive about the care that they received. One relative said, ‘‘Everyone is so lively and considerate. Nothing is ever too much trouble. I would give the all the staff here an A1 plus.’’

People were treated with kindness, respect and compassion and their privacy, dignity and independence were promoted.

People’s communication needs were not always met as communication methods for people living with dementia had not been fully explored.

People had a limited choice of activities which they could take part in.

The environment at the service needed some development to make it more supportive to people living with dementia. Plans were in place to improve upon this.

We have made recommendations to the service about improving communication methods and the premises for people living with dementia.

Systems and process in place at the service kept people safe in all areas of their care including the administration of medicines.

There were enough staff on shift to support people and robust recruitment checks were carried out before staff started working at the service.

Staff received induction, training and supervision to ensure that they had the right skills and abilities to support people.

People were supported to eat and drink enough to maintain a balanced diet.

Staff referred people to health professionals where necessary and supported people to lead healthy lives.

Complaints were responded to appropriately by the registered manager.

People were supported with dignity and respect at the end of their lives.

The registered manager had a system of audits in place that were used to monitor and improve the quality of the service.

Regular feedback was collected from people and their relatives about the best way to support people.

People, their relatives and staff felt well supported by the registered manager.

Rating at last inspection: Good (report published 21 September 2016)

Why we inspected: This was a planned inspection based on the rating at the last inspection. During this inspection we found evidence continued to support the rating of good. One KLOE (Responsive) has now been rated as Requires Improvement. More information is in the full report.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

This unannounced inspection took place on 18 August 2016. At our previous inspection in January 2015, we found that relatives and staff were not happy about the management changes. During this inspection, relatives and staff now welcomed the management changes that had been made because they could see improvements to the service.

Orchid Lawns provides nursing care and support for up to 24 older people living with dementia and needs relating to their mental health. At the time of our inspection there were 23 people who lived at the home.

The home had a registered manager, as is required by the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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 we found that people were safe at the home. Staff were aware of the safeguarding process. Personalised risk assessments were in place to reduce the risk of harm to people, as were risk assessments in relation to the running of the home. These were reviewed regularly. Accidents and incidents were recorded and the causes of these analysed so that preventative action could be taken to reduce the number of occurrences. There were effective processes in place to manage people’s medicines and referrals to other health and social care professionals were made when appropriate to maintain people’s health and well-being.

There were enough skilled, qualified staff to meet people’s needs. Staffing levels had been based on the dependency levels of the people who lived at the home. There were no permanent staff vacancies at the home, although the registered manager was recruiting for bank staff to cover when permanent staff were absent. Robust recruitment and selection processes were in place and the provider had taken steps to ensure that staff were suitable to work with people who lived at the home. Staff were trained and supported by way of supervisions.

People or relatives acting on their behalf had been involved in determining their care needs and the way in which their care was to be provided. Their consent was gained before any care was provided and the requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were met. Relatives were involved in the regular review of people’s care needs and were kept informed of any changes to a person’s health or well-being.

People had a choice of good nutritious food that they liked and their weight was monitored, with appropriate referrals made to other healthcare professionals when concerns were identified.

There was an up to date complaints policy in place and a notice about the complaints system was on display at the entrance to the home. The registered manager had introduced more informal methods of gaining feedback form visitors and healthcare professionals who attended the home. Actions taken as a result of any feedback were shared with people. A number of leaflets on the notice boards around the home included information about the service and organisations that could be contacted for support or to report concerns.

There was a very friendly, family atmosphere at the home. People, relatives and staff were able to make suggestions as to how the service was provided and developed. The home had forged links with a number of local organisations which provided support to the development of the service.

An effective quality assurance system was in place.

This unannounced inspection took place on 05 January 2016. At our previous inspection in June 2015 we found that there was insufficient activity to support people with their interests, there was no registered manager in place and quality assurance systems had not been embedded. During this inspection we found that an activities coordinator had been appointed and the quality assurance system was effective. A new manager was in place but their appointment was not popular with all of the staff and relatives of people who lived at the home.

Orchid Lawns provides nursing care and support for up to 24 older people with dementia and needs relating to their mental health. At the time of our inspection there were 21 people who lived at the home.

The home had not had a registered manager, as required by the Care Quality Commission (CQC), since May 2014, although the recently appointed manager had applied to become the registered manager. A registered manager is a person who has registered with the CQC 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 we found that people were not always safe at the home. Staff were aware of the safeguarding process. Personalised risk assessments were in place to reduce the risk of harm to people, as were risk assessments connected to the running of the home. These were reviewed regularly. Accidents and incidents were recorded and the causes of these analysed so that preventative action could be taken to reduce the number of occurrences. There were effective processes in place to manage people’s medicines and referrals to other health and social care professionals were made when appropriate to maintain people’s health and well-being. However, people’s personal emergency evacuation plans contained insufficient detail for staff to be able to safely evacuate them in case of an emergency and staff who administered medicines were repeatedly interrupted when doing so. This meant that there was an increased risk of errors being made and delays in people receiving their medicines.

There were enough skilled, qualified staff to provide for people’s needs. Staffing levels had been calculated in accordance with current guidance and based on the dependency levels of the people who lived at the home. Although a number of permanent staff had indicated that they would be leaving the service a recruitment exercise was underway and the provider was taking steps to dissuade staff from leaving. Robust recruitment and selection processes were in place and the provider had taken steps to ensure that staff were suitable to work with people who lived at the home. They were trained and supported by way of supervisions.

People or relatives acting on their behalf had been involved in determining their care needs and the way in which their care was to be delivered. Their consent was gained before any care was provided and the requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were met. Relatives were involved in the regular review of people’s care needs and were kept informed of any changes to a person’s health or well-being.

People had choice of good nutritious food that they liked and their weight was monitored with appropriate referrals made to other healthcare professionals when concerns were identified.

There was an up to date complaints policy in place and a notice about the complaints system was on display in the entrance of the home. However, the manager had not always followed the policy when dealing with expressions of dissatisfaction. There were a number of other information leaflets on the notice boards around the home which included information about the service and organisations that could be contacted for support or to report concerns.

There was a very friendly, family atmosphere about the home. People, relatives and staff were able to make suggestions as to how the service was provided and developed, although they had not always been consulted on changes made to the home.

An effective quality assurance system was in place.

This unannounced inspection took place on 01 June 2015. At our previous inspection in October 2014 we found that there was insufficient staff to provide for people’s needs. This was a breach of Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 which corresponds to Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found that improvements had been made to the level of staffing and additional improvements were planned.

Orchid Lawns provides nursing care and support for up to 24 older people with dementia and needs relating to their mental health. At the time of our inspection there were 16 people who lived at the home.

The home does not have a registered manager as required by the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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 the time of this inspection the home had been without a registered manager for over 12 months and was being managed by a peripatetic manager from the provider’s organisation on an interim basis.

During our inspection we found that people were safe at the home. Staff were aware of the safeguarding process. Personalised risk assessments were in place to reduce the risk of harm to people, as were risk assessments connected to the running of the home. These were reviewed regularly. Accidents and incidents were recorded and the causes of these analysed so that preventative action could be taken to reduce the number of occurrences. There were effective processes in place to manage people’s medicines and referrals to other health and social care professionals were made when appropriate to maintain people’s health and well-being.

There were enough skilled, qualified staff to provide for people’s needs. Staffing levels had been calculated in accordance with current guidance and based on the dependency levels of the people who lived at the home. The provider had recently agreed to increase the staffing level above that calculated as being needed. Most care was delivered by permanent staff with the reliance on agency staff reduced significantly. Recruitment and selection processes were in place and the provider had taken steps to ensure that staff were suitable to work with people who lived at the home. They were trained and supported by way of supervisions.

People or relatives acting on their behalf had been involved in determining their care needs and the way in which their care was to be delivered. Their consent was gained before any care was provided and the requirements of the Mental Capacity Act 2005 and associated Deprivation of Liberty Safeguards were met. Relatives were involved in the regular review of people’s care needs and were kept informed of any changes to a person’s health or well-being.

People had choice of good nutritious food that they liked and their weight was monitored with appropriate referrals made to the dietitian when concerns were identified.

There was an up to date complaints policy in place and a notice about the complaints system was on display in the entrance of the home. There were a number of other information leaflets on the notice boards around the home which included information about the service.

There was a very friendly, family atmosphere about the home. There was an open culture and staff were supported by the managers. Staff were aware of the visions and values of the provider. People, relatives and staff were able to make suggestions as to how the service was provided and developed. A quality assurance system was in the process of being introduced.

We inspected Orchid Lawns on 23 October 2014. Orchid Lawns provides nursing care and support for up to 24 older people with dementia and needs relating to their mental health. At the time of our inspection there were 16 people who lived at the home.

The home is required to have 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 the time of our inspection, the manager’s application to become the registered manager for Orchid Lawns was being processed by CQC.

When we last inspected Orchid Lawns on 13 December 2013 we found that the provider was not meeting the legal requirements of a number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in respect of safeguarding, care records and supporting staff. The provider told us that they would take action to make improvements by April 2014. During this inspection we found that the provider had taken appropriate steps to rectify the breaches we had found previously.

There were insufficient staff to safely meet the needs of people in this home.

The staff who worked at the home had the necessary skills to care for and support people. Robust recruitment and induction processes were in place. Staff had received training safeguarding. The requirements of the Mental Capacity Act 2005 were understood and met by staff.

Risk assessments and management plans were in place to enable people to have as much independence as possible whilst keeping them safe and to manage risk in connection with the operation of the home.

People’s needs were assessed and care and support was planned and delivered in line with their individual care plan. They were supported to access healthcare services and their medicines were managed and administered safely. They liked the food they were offered and their specific dietary requirements were catered for.

Staff were caring and respectful, interacted with people very positively and knew the people that they cared for well. Visitors were welcome at the home at any time and the manager held meetings for relatives to discuss matters concerning the home.

Although there was a creative therapist in post people did not receive much support to participate in meaningful activities or maintain their hobbies and interests.

The provider had a complaints policy which had been made available to people and their relatives. The manager had an open door policy for people and relatives to call in at any time to discuss any concerns with them. However, relatives felt that there was little managerial presence in the home.

Staff felt supported by the manager although they went to the nurse for guidance. Staff knew and understood their roles. A number of quality audits had been undertaken. However, where actions had been identified there was no evidence that these had been completed.

During this inspection we found there was a breach of Regulation 22 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

Prior to our inspection the Care Quality Commission received information of concern about the care and welfare of people at Orchid Lawns and the systems in place for the support and treatment of people. It was alleged that some people were not supported to receive effective personal care and that staff did not always undertake manual handling using best practice techniques or appropriate equipment. The allegations stated people were not given sufficient stimulation and were left unattended for periods of time without being given pressure care.

Further allegations included concerns about the accurate completion of care records and the training staff received to enable them to undertake their roles effectively. Whilst we had no information relating to any specific harm caused to people, it was suggested the systems in place and the care provided could pose a risk to people.

People told us they were happy and we observed they were calm and relaxed in the presence of staff. We did however find that the care records were not always reflective of the current care needs.

Although there was manual handling equipment within the home, staff reported there was not sufficient available for the amount of people required to use this. We found out of three bathrooms, only one of the baths was in working order, with parts being required for two of them.

We found staff had received appropriate training but were not always supported with regular supervision or staff meetings.

We visited Orchid Lawns on 25 June 2013, to review improvements within the home following the enforcement action we took against the provider in April 2013. On arrival at our last inspection, we had found there were insufficient staff available to protect the health and well-being of people at Orchid Lawns, because two of the three staff on duty were asleep. On this visit, we were made aware that some staff changes had been made to address this incident. We looked at the staff rota and found that the ratio of staff was appropriate to meet the needs of people.

During our last inspection, we found that although people's personal preferences for daily living had been detailed within the records, these were not always considered when care was delivered. Therefore to ensure this took place, we observed the engagement and interactions between staff and people who used the service. We found these were achieved in a relaxed and calm manner. Staff considered people’s choices, took their time to explain what they were going to do and respected people’s decisions. Staff were observed to be attentive to the needs of people and could tell us about individual likes, dislikes and preferences within people’s daily routines.

Staff told us that since our last visit, the home had made improvements which had benefitted people. We found that all care staff on duty had been provided with training to use the bath equipment safely and effectively.

This inspection of Orchid Lawns was carried out in response to information of concern received by the Care Quality Commission (CQC). The information alleged there was insufficient personal protective equipment (PPE) made available to night staff, and that night care routines were not focused on the needs or wishes of people who used the service. This visit took place on the 23 April 2013 at 5am.

On arrival we found there was insufficient staff available to protect the health safety and well being of people at Orchid Lawns, because two of the three staff on duty were asleep.

As part of this inspection we reviewed the care documentation for four people in this home. We found care plans and risk assessments were detailed and kept under review and reflected people's changing needs. We noted people's personal preferences and wishes had been sought and were recorded, however we observed these were not always considered when care was delivered.

We spoke with two people who used the service, and observed staff interactions with people throughout this inspection. We observed staff were respectful and treated people with dignity. One person told us, "I came here not expecting friendship, but it's alright here."

This home provided a safe and secure premises for the people who lived there. The manager told us a refurbishment programme was due to commence, which would replace furniture and fittings which were old or damaged.

When we visited Orchid Lawns on 02 May 2012 we found that people had varying levels of communication which made it difficult for us to discuss their care with them in any depth. Therefore we used a number of different methods including observations, and talking with people’s relatives, to help us understand their experiences.

There was a calm and relaxed atmosphere in the home, and we observed that people looked clean and comfortable. When people required assistance and support this was recognised and addressed by staff, who we noted were caring and respectful in the way they delivered care.

We observed that people looked at ease in the company of the staff who cared for them, and the relative of one person who used this service told us. “They are absolutely brilliant here, people are always treated with dignity, it couldn’t be better”. We also spoke with someone from the advocacy service, who visited Orchid Lawns once a fortnight. They told us. “The care is always very good here, there is a strong forum of relatives who are also very happy with the service”.

When we visited Orchid Lawns on 13 March 2012 we noted that everyone living at the home, had conditions which affected their cognitive functioning. This meant that their ability to communicate with, and understand us was very limited. We observed that people looked content and comfortable, and where they required attention and support this was recognised and addressed by staff. However the shortage of staff on the day of our visit meant that there was sometimes a delay in responding to people’s needs.

We saw staff interacting with people in a positive way and observed a number of different activities being delivered very effectively during the course of the day.

There was a continuous flow of visitors at Orchid Lawns at the time of our visit, and we spoke with several of them. All were complimentary about the care people received in this home, and they spoke highly of the staff in general. However some commented on how low staff moral had been over recent weeks. They indicated that this had had a negative impact on the atmosphere in the home.

When we visited Orchid Lawns on 23 January 2012 we noted that everyone living at the home, had conditions which affected their cognitive functioning. This meant that their ability to communicate with, and understand us was very limited. However we observed that people looked content and comfortable, and where they required attention and support this was recognised and addressed swiftly by staff.

We observed periods of engagement and conversation between the staff and people who lived in the home, and noted that at meal times and when physical care was being delivered, communication was positive. Although we did not observe that anyone was left for long periods without some type of interaction with staff, we concluded that some people would benefit from more focused / meaningful activities which could improve their well being and quality of life.

People were appropriately dressed and looked clean and well cared for, and where people needed support or assistance with personal care this was done in the privacy of their bedroom or the bathroom to protect their dignity.

During our visit on 6 October 2011, we were unable to speak with people who use the service about the care and support they receive as many of the people living in the home were unable to communicate verbally. We spent time observing and listening to the care people received.