We carried out an unannounced comprehensive inspection of this service on 1 and 5 February 2018.

The Orchards is a home for people who receive accommodation and nursing care. A maximum of 72 people can live at the home. There were 55 people living at home on the day of the inspection. At the last inspection in November 2017, the service was rated Requires Improvement. This was because the provider had failed to ensure systems and processes were place to assess, monitor and mitigate risk to people living in the home. The provider had a condition placed on their registration to provide a monthly review to demonstrate how they were working towards making the required improvements. This was to ensure people living at the home remained safe while improvements were made. At this inspection we found the service had improved and was now Good overall.

People living in the home told us that staff assistance maintained their safety and made the home safe. People were able to minimise the risk to their safety and were supported by staff offering guidance or care that reduced those risks. Nursing and care staff understood their responsibilities in reporting any suspected risk of abuse and the expected action that would be taken. Staff were available for people who had their care needs met in a timely way. People’s medicines were managed and administered for them by the nursing staff in safe way to support their health needs.

Staff were knowledgeable about people’s support needs. Staff told us the training they received and guidance from managers maintained their skill and knowledge. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People had a choice of where they ate their meals, and people enjoyed the food on offer. Where people needed support to eat and drink enough to keep them healthy, staff provided one to one assistance. People had access to other healthcare professionals from the point of admission and ongoing review which provided treatment, advice and guidance to support their health needs.

People were seen chatting and spending time with staff. Relatives we spoke with told us staff were kind and friendly. Staff told us they took time to get to know people and their families. Staff supported people, some of whom were on short visits to the home. People’s privacy and dignity was supported by staff when they needed personal care or assistance. People’s daily preferences were known by staff and those choices and decisions were respected. Staff promoted people’s independence and encouraged people to be involved in their care and support.

People’s care needs had been planned, with their relatives involvement where agreed, which had been recorded in care plans and had been reviewed and updated regularly. People also told us they enjoyed the social aspect of the home and the activities offered which had improved since our last inspection.

People and relatives knew how to make a complaint if needed. People also told us they would talk with staff if they had a question or concern. The provider had policies and processes in place to ensure that any complaints received were investigated and responded to.

Since the last inspection the manager had developed the existing quality assurance systems and people had the opportunity to state their views and opinions with surveys and meetings. Audits had been fully implemented to identify and record the required ongoing improvements. However, a registered manager will need to be in post and the provider to demonstrate consistent and sustainable good practice overtime.

At the time of our last comprehensive inspection in February 2017 we found breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008. We found the provider to be in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because people had not always received their medicines as prescribed and poor oversight and record keeping systems meant that medicines were not always managed safely or recorded effectively.

We also found the provider to be in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 because record keeping and governance systems and processes had not been operated effectively to assess, monitor and improve the quality and safety of the service. We found that records were not always complete, recorded accurately and some information was missing.

We served warning notices to the provider for both of these breaches of regulations and asked the provider to send us an action plan to show how they would meet the legal requirements of the regulations. We gave them until 30 June 2017 to demonstrate their compliance.

We undertook this focused inspection on 02 August 2017 to check the provider had followed their plan and to monitor their compliance with the legal requirements of the regulations, under two of our key lines of enquiry; whether the service being provided to people was safe and well-led. This report only covers our findings in relation to these two key lines of enquiry. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Orchards on our website at www.cqc.org.uk.

The Orchards provides accommodation and personal care for up to 72 people who require nursing or personal care. At the time of our inspection there were 60 people living at the home. The home is designed over two floors. The ground floor accommodates people on a permanent basis who require nursing and personal care, whilst the first floor accommodates people on both a permanent basis, but also where people require short-term, interim care for either respite or re-enablement purposes, whilst a long-term care plan is considered.

The service was required to have a registered manager in place as part of the conditions of their registration. There was a registered manager in post at the time of our visit because the provider had deployed a 'turn-around manager' to the home who had registered with us since our last inspection. A ‘turn-around manager’ is a manager that the provider deploys to support homes that require ‘re-establishing’. 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.

We found that some improvements had been made to promote the safety and governance of the service. However, the shortfalls that we identified within this inspection in relation to the governance of the service showed that further improvements were still required. The provider had failed to make sufficient improvements to the efficiency of their quality assurance systems within the stipulated time frame. This meant that this inspection was the third consecutive inspection whereby the provider had failed to meet the requirements of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see what further action we have taken at the end of this report.

Everyone we spoke with recognised that improvements had been made to the management of medicines within the home and people told us they received their medicines as prescribed. People’s needs were also met in a timelier manner because improvements had been made to the way in which staff were deployed and organised

At our last inspection in September 2016 we found that people did not always receive their medicines safely, effectively or as prescribed and the provider was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found that despite an increase in staffing levels, the deployment of the staff was not always effective to ensure that people’s needs were met consistently and/or in a timely manner and a further breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was identified. In addition, we found that the provider’s quality monitoring systems were not always implemented effectively so that they were able to identify shortfalls within the service and a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 was also identified. We asked the provider to send us an action plan to inform us of what action they planned to take in order to make the required improvements and become compliant with the regulations, which we received in October 2016. At this inspection, some improvements had been made but we continued to find on-going concerns which meant further breaches of regulations were identified.

This inspection took place on 08, 15 and 22 February 2017. All of the inspection visits were unannounced including an evening inspection visit which was conducted on 15 February 2017.

The home provides accommodation and support for up to 72 people who require nursing or personal care. At the time of our inspection, there were 54 people living at the home. The home is designed over two floors. The ground floor accommodates people on a permanent basis who require nursing and personal care, whilst the first floor accommodates people on both a permanent basis, but also where people require short-term, interim care for either respite or re-enablement purposes, whilst a long-term care plan is considered.

The service was required to have a registered manager in place as part of the conditions of registration. There was not a registered manager in post at the time of our visit because the person who had registered to manage the service since our last inspection had recently left. The provider had re-deployed a ‘turn-around manager’ who was employed by the provider to support homes that required ‘restabilising’. The ‘turn-around manager’ had been registered for the management of this location previously back in 2016 and was in the process of re-applying for their registration with us. We have received an application for us to consider. 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 did not always receive their medicines as prescribed and poor quality assurance and record keeping systems meant that medicines were not always managed or recorded effectively. This was a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider had some systems in place to monitor the safety and quality of the service but these had not always been used effectively to identify areas in need of improvement or to sustain the improvements made. Record keeping and governance within the service were also found to be ineffective. Records were not always complete, recorded accurately and some information was missing. Staff did not always have the information or time to get to know people to ensure that people received care that was personalised and that met their individual needs. This was a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People did not always feel involved in the plan

At our last inspection on 7 October 2015 we found that people did not always receive their medications safely, effectively or as prescribed and the provider was in breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found that despite an increase in staffing levels following a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in June 2015, the deployment of the staff was not always effective to ensure that people’s needs were met consistently and in a timely manner. At this inspection we found on-going concerns relating to these regulations.

This inspection took place on 8 and 9 September 2016. This was an unannounced inspection.

The home provides accommodation and support for up to 72 people who require nursing or personal care. At the time of our inspection, there were 60 people living at the home. The home is designed over two floors. The ground floor accommodates people on a permanent basis who require nursing and personal care, whilst the first floor accommodates people on both a permanent basis, but also people who require short-term, interim care for either respite or re-enablement purposes, whilst a long-term care plan is considered.

The service was required to have a registered manager in place as part of the conditions of registration. However, there was not a registered manager in post at the time of our visit because the person who was registered to manage the service had recently left. However, the provider had appointed a new manager who was in the process of applying for their registration with us. 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.

The service was not consistently safe, effective, caring or well-led because the provider had not always ensured that people received safe, person-centred care.

People did not always receive the care and support they required when they required it, because there was not always adequate numbers of staff available to meet their needs in a timely manner. Insufficient staffing levels also meant that people did not always receive their medications as prescribed and staff did not always have the time to get to know people or to spend time with people in order to provide person-centred care that was individual to people’s specific care needs.

The provider’s recruitment systems and processes were not always implemented effectively to ensure that staff were recruited safely.

Care records were not always complete and risks assessments were not always specific to peoples’ individual care needs so staff did not always have the information to support people safely.

Not all people living at the home were actively encouraged and supported to engage in activities that were meaningful and accessible to them. However, people were supported to maintain positive relationships with their friends and relatives.

It was not always clear that people received care and support with their consent because key systems and processes had not always been followed or documented to evidence this. However, most people were supported to make day to day choices and decisions, such as meal options. This meant that most people had food that they enjoyed and any risks associated with their diet were identified and managed safely within the home.

People were supported to maintain good health because staff worked closely with other health and social care professionals when necessary. jobs.

People were supported by staff that were nice, helpful and caring and most people were also cared for by staff that protected their privacy and dignity and respected them as individuals.

People were encouraged to b

At our last inspection on 6 June 2015 staffing levels were not sufficient to ensure people received safe care and there was a breach of regulations. The provider sent us an action plan to tell us what action they were taking to ensure people were supported safely at all times and minimise any risk of harm. At this inspection we found that the provider had increased staffing levels so peoples care needs could be met. However the deployment of staffing was not always used effectively.

The Orchards provides accommodation and support for up to 72 people with nursing and personal care needs some of whom were living with dementia. There were 52 people living in the home at the time of our visit.

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 were protected from unnecessary harm because risk assessments had been completed and staff knew how to minimise the risk when supporting people with their care.

People were protected from the risk of avoidable harm because systems and processes were in place to protect people. Staff understood the different types of abuse and knew what actions to take if they thought a person was at risk of harm.

There were sufficient numbers of staff that had received appropriate training so that they were able to meet people’s needs. However improvements were required in how the service ensured staff were suitable deployed to meet people’s needs consistently.

People did not always receive their medication as prescribe to ensure they remain healthy.

Staff sought people’s consent before providing care and support. Staff had up to date knowledge, and training and understood how to protect people’s human rights.

People were able to make decisions about their care and were actively involved in how their care was planned and delivered. Referrals were made in consultation with people who used the service if there were concerns about their health.

People were able to raise their concerns or complaints and these were thoroughly investigated and responded to. People were confident they were listened to and their concerns taken seriously.

Staff did not always support people appropriately with their meals and provide equipment to enable them to remain independent.

Systems were in place to monitor and check the quality of care provided but these were not always used effectively to improve the service and take action when required.

We carried out an unannounced comprehensive inspection of this service on 31 July 2014. At which a breach of legal requirements was found. This was because the systems to monitor the quality of care were not always effective.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook a focused inspection on the 8 October 2014 2 April 2015 to check that they had followed their plan and to confirm that they now met legal requirements. We found that improvements had been made but some further work was needed and we asked the provider to give us a plan of what action they were taking.

The inspection took place on 6 June 2015 and was unannounced. This was a focused inspection because we had received some concerns about staffing level in the home. This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘The Orchards’ on our website at www.cqc.org.uk’

The Orchards provides accommodation and support for up to 72 people with nursing and personal care needs some of whom were living with dementia.

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.

There were not always enough staff on duty to ensure that people were adequately supervised so that their care needs were met in the way they wanted. Staff shortages meant that emergency buzzers were not responded to quickly, meals were cold by the time some people got them, some people did not get the support they needed at meal times and medication was not given at the times prescribed. This is a breach of Regulation18 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service. This inspection was unannounced.

The Orchards provides personal and nursing care for up to 72 people. People living in the home may be older or younger people with physical disabilities, dementia or have health conditions that require nursing. Bedrooms are provided over two floors and each bedroom has en suite facilities. There are communal areas consisting of lounges, dining rooms, activity room and courtyard garden for people to use. There are adaptations and equipment available so that the needs of people with reduced mobility can be supported and access all areas of the home.

At our previous routine inspection of 15 and16 October 2013 we found that there had been breaches of legal requirements in respect of managing people’s dignity, nutrition and records management. At our responsive inspection of February 2014 we found that people’s dignity was being maintained however there were other breaches of legal requirements. These were in respect of meeting people’s needs, management of medicines, quality monitoring of the service and records management. At this inspection we saw that some improvements had been made but further improvements were needed. Following our inspection we held a meeting on13 August 2014 to discuss our findings and decide on the actions we were going to take. You can see what actions we have told the provider to take at the back of the full version of the report.

There was no registered manager in post at the time of this inspection however the provider had appointed an acting manager. This meant that actions had been taken to someone who would be responsible for the day to day management of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

There had been a lack of consistent management in the home since October 2011 and this meant that people had not always received good quality care and staff were not always provided with support and leadership. There were some audits that monitored the service provided but there was not always adequate analysis and action planning to address identified issues. This was a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

At the time of our inspection there were 48 people living in the home. We saw that people were not always safe and protected from harm because the service continued to be in breach of Regulation13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to the shortfalls in the safe administration of medicines. Our checks on the amounts of medicines in the home showed that some people had either been given more or less than the prescribed levels of medicines. This meant that their medical conditions were not always treated appropriately and according to the prescriber’s instructions. The necessary information to ensure that medicines given disguised in food or drink, on a when required basis and when people were responsible for their own medicines was not in place. As a result of these breaches we have decided to take enforcement action to ensure the future safe administration of medicines.

The provider had taken steps to protect people from abuse and although most people told us they felt safe in the home two people told us they were shouted at by staff. They were unable to give us specific details about this so we brought it to the provider’s attention to monitor. Recruitment procedures ensured that checks were undertaken to ensure that staff were suitable to work with vulnerable adults. Staff received training and care records contained the information staff needed to support people safely.

People’s rights were not always protected because meetings had not been held to determine that the actions taken were in people’s best interests when they were not able to make decisions for themselves. No Deprivation of Liberty Safeguards (DoLS) applications had been made although bed rails were in use and they could restrict people’s liberty.

We saw that staff were able to meet people’s basic needs but at times staff were not available to support people and there had been a high dependency on agency staff so that people did not always know the staff supporting them. Staff recruitment was underway to address these issues.

People’s nutritional and hydration needs were planned for and advice obtained when people were at risk of poor nutrition. People had a diet that was varied, nutritional and presented mashed or pureed where needed so that people were protected from the risks of choking. Improvements could be made to the management of mealtimes.

People’s health care needs were met by referral to the appropriate healthcare professionals including doctors, nurses, dieticians and chiropodists

People with capacity were able to choose whether they took part in activities but some people without capacity received inconsistent access to activities.

We visited the service in response to concerns that had been raised with us in regards to staffing levels. At our last inspection in 19 February 2014 we found that staffing levels were not adequate to meet the needs of people living there and improvements were required to ensure people’s care needs were met.

Before our visit we were told by relatives that staffing levels at the home had been reduced. This had resulted in people’s care needs not being met. For example, call bells were not being answered and people were remaining in bed because there were not enough staff on duty to assist people to get up. We visited the home to establish if people’s needs were met.

On the day of our visit there were eighteen staff on duty. This consisted of four registered nurses and fourteen care staff across the home. We spoke with the area manager, acting manager, four staff, one relative and a social worker. In addition we spoke with nine people who lived there.

We spoke with people who used the service to help us gather evidence about whether improvements had been made since our last inspection. Below is a summary of what we found.

The detailed evidence supporting our summary can be read in our full report.

Is the service well led

All staff spoken with told us, recent changes in regards to staffing levels had not been effective. The changes had resulted in dissatisfaction with the service provided. The acting manager and area manager had identified that the changes had not been successful. Following meetings with people who lived there and their relatives changes had been made to restore the staffing structure. This meant the provider had listened to people’s views and made the necessary improvements. The area manager told us that this would be closely monitored.

You can see our judgements on the front page of this report.

A new provider had taken over the home in October 2011.They had placed an experienced management team into the home. They had implemented a number of new systems and procedures. They had looked at all aspects of the service and completely overhauled the way care was provided.

We observed good interaction between staff and people living at the home. People were now treated with respect, and involved in making decisions about their day.

People told us they were now much happier with the care they received.

Comprehensive inspection of 31 July 2014

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008 and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service. This inspection was unannounced.

The Orchards provides personal and nursing care for up to 72 people. People living in the home may be older or younger people with physical disabilities, dementia or have health conditions that require nursing. Bedrooms are provided over two floors and each bedroom has en suite facilities. There are communal areas consisting of lounges, dining rooms, activity room and courtyard garden for people to use. There are adaptations and equipment available so that the needs of people with reduced mobility can be supported and access all areas of the home.

At our previous routine inspection of 15 and16 October 2013 we found that there had been breaches of legal requirements in respect of managing people’s dignity, nutrition and records management. At our responsive inspection of February 2014 we found that people’s dignity was being maintained however there were other breaches of legal requirements. These were in respect of meeting people’s needs, management of medicines, quality monitoring of the service and records management. At this inspection we saw that some improvements had been made but further improvements were needed. Following our inspection we held a meeting on13 August 2014 to discuss our findings and decide on the actions we were going to take. You can see what actions we have told the provider to take at the back of the full version of the report.

There was no registered manager in post at the time of this inspection however the provider had appointed an acting manager. This meant that actions had been taken to someone who would be responsible for the day to day management of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

There had been a lack of consistent management in the home since October 2011 and this meant that people had not always received good quality care and staff were not always provided with support and leadership. There were some audits that monitored the service provided but there was not always adequate analysis and action planning to address identified issues. This was a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

At the time of our inspection there were 48 people living in the home. We saw that people were not always safe and protected from harm because the service continued to be in breach of Regulation13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 in relation to the shortfalls in the safe administration of medicines. Our checks on the amounts of medicines in the home showed that some people had either been given more or less than the prescribed levels of medicines. This meant that their medical conditions were not always treated appropriately and according to the prescriber’s instructions. The necessary information to ensure that medicines given disguised in food or drink, on a when required basis and when people were responsible for their own medicines was not in place. As a result of these breaches we have decided to take enforcement action to ensure the future safe administration of medicines.

The provider had taken steps to protect people from abuse and although most people told us they felt safe in the home two people told us they were shouted at by staff. They were unable to give us specific details about this so we brought it to the provider’s attention to monitor. Recruitment procedures ensured that checks were undertaken to ensure that staff were suitable to work with vulnerable adults. Staff received training and care records contained the information staff needed to support people safely.

People’s rights were not always protected because meetings had not been held to determine that the actions taken were in people’s best interests when they were not able to make decisions for themselves. No Deprivation of Liberty Safeguards (DoLS) applications had been made although bed rails were in use and they could restrict people’s liberty.

We saw that staff were able to meet people’s basic needs but at times staff were not available to support people and there had been a high dependency on agency staff so that people did not always know the staff supporting them. Staff recruitment was underway to address these issues.

People’s nutritional and hydration needs were planned for and advice obtained when people were at risk of poor nutrition. People had a diet that was varied, nutritional and presented mashed or pureed where needed so that people were protected from the risks of choking. Improvements could be made to the management of mealtimes.

People’s health care needs were met by referral to the appropriate healthcare professionals including doctors, nurses, dieticians and chiropodists

People with capacity were able to choose whether they took part in activities but some people without capacity received inconsistent access to activities.

Focused inspection of 8 October 2014

We found that the service had improved greatly since the last inspection in the way they managed medicines. We found that medicines were now being managed safely and people were receiving their medicines as prescribed.