Orchard House Nursing Home is a ‘care home’. 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 Nursing Home accommodates up to 44 people in one adapted building. The service specialises in providing end of life care. At the time of our inspection 35 people were using the service.

At our last comprehensive inspection on 30 January and 2 February 2017 we rated the service ‘requires improvement’ and found them in breach of legal requirements relating to safe care and treatment, safeguarding and good governance. We undertook a focused inspection on 19 July 2017 to check what action the provider had taken in response to the breaches. Whilst the service remained rated ‘requires improvement’, we found appropriate action had been taken to improve the service and they were no longer in breach of the regulations. At this inspection on 27 March 2018 we rated the service ‘good’ overall and for each key question.

A registered manager was 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 received personalised care that met their needs. Detailed care plans were in place which detailed people’s support needs as well as information about their life histories and preferences. Staff respected people’s end of life choices. Staff ensured people’s dietary requirements were met and supported them to access healthcare services. Staff adhered to the principles of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Staff adjusted their communication methods to ensure people understood them and they empowered people to make decisions about their care.

Staff treated people with kindness and compassion. They respected people’s dignity and privacy. People’s families were welcome to visit the service and there were unrestricted visiting arrangements. A pastor visited the service regularly to support people’s religious preferences. The service had also arranged a befriending service for people that did not have regular visitors.

People were supported by staff that had the knowledge, skills and experiences to meet their needs. Staff received regular training, supervision and appraisals. There were sufficient numbers of staff to keep people safe. Staff mitigated risks to people’s safety and followed safeguarding adults’ procedures. Staff adhered to procedures to minimise the risk of infections and safe medicines management processes were in place.

The leadership team had been strengthened with the addition of a lead nurse. The service’s quality assurance processes were more robust and enabled ‘live’ tracking of key performance data. The staff had built close working relationships with the clinical commissioning group, the local authority and staff from other care services. Staff welcomed feedback from people using the service and their relatives. A complaints process remained in place, although no complaints had been received since our last inspection.

The registered manager adhered to the requirements of their CQC registration.

We carried out an unannounced comprehensive inspection of this service on 30 January and 2 February 2017. At which breaches of legal requirements were found in regards to safe care and treatment, safeguarding service users from abuse and improper treatment and good governance. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements. They stated they would take the necessary action to address the breaches by 8 May 2017.

We undertook this focused inspection on 19 July 2017 to check they had followed their plan and to confirm they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Orchard House Nursing Home’ on our website at www.cqc.org.uk.

Orchard House Nursing Home provides accommodation with nursing and personal care for up to 44 people. This includes palliative and end-of-life care. At the time of our inspection there were 34 people using the service.

Since our comprehensive inspection a registered manager had been appointed. 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 manager was registered with the Care Quality Commission on 16 June 2017.

Improvements had been made since our previous inspection. Environmental changes had been made to ensure water temperatures were within a safe range, hazardous chemicals were stored securely, hazards in the garden had been addressed and minimised and bathrooms had been decluttered. We saw that new processes had been implemented to review medicines stock levels, however, staff needed reminding to record the dose administered for medicines prescribed at a variable dose to ensure accurate stock checks could be undertaken.

The registered manager had liaised with the local authority safeguarding team to seek clarification and review arrangements to deprive people of their liberty. The registered manager was aware of when applications to deprive people of their liberty should be made and kept track of the applications that had been authorised.

Processes had been strengthened and improved to review the safety of service delivery, and ensure ongoing monitoring of the quality of support provision.

To revise the provider’s ratings from ‘requires improvement’ to ‘good’ requires evidence of ongoing consistent good practice. This was achieved in regards to the key question, ‘Is the service effective?’. We have not revised the rating for the key question, ‘Is the service safe?’ due to minor improvements still required in regards to medicines management. We have also not reviewed the rating for the key question, ‘Is the service well-led?’ as we required more time to assess whether the improvements made will be sustained.

This inspection took place on 30 January and 2 February 2017 and was unannounced. At our last comprehensive inspection in January 2016 we found one breach of regulations in relation to good governance. When we carried out a follow-up inspection in June 2016 we found the provider had made the necessary improvements and the service was meeting legal requirements.

Orchard House provides accommodation with nursing and personal care for up to 44 people. This includes palliative and end-of-life care. At the time of our inspection there were 35 people using the service.

The service was required to have a registered manager in post but did not have one at the time we carried out this inspection. However, the home did have a manager who had recently been the registered manager at another service operated by the same provider and was in the process of applying to become the registered manager at Orchard House. 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 this inspection we found three breaches of regulations in relation to safe care and treatment, safeguarding service users from abuse and improper treatment and good governance. Some taps in handwashing sinks produced water that was hotter than the maximum safe temperature. Chemicals were not always stored securely and in appropriately labelled containers. Some risks around people’s use of the garden and the storage of large pieces of equipment in bathrooms were not assessed and managed appropriately. There was not a robust system in place to monitor and check stock levels of some medicines, meaning errors or unauthorised removal of medicines could go unnoticed. Additionally, we found that some people may have been deprived of their liberty without the correct legal safeguards in place because the provider had not always followed legal requirements in relation to this. The provider had quality checks but they were not robust enough because they had not identified these problems.

You can see what action we told the provider to take at the back of the full version of the report.

The provider had systems in place to protect people from the risks of infection and poor hygiene, including food hygiene. People had individual risk assessments and management plans to help protect them from risks specific to them and the care they received. Staff received appropriate training around safeguarding people from abuse and there were procedures in place to enable staff to identify and report possible abuse promptly.

There were enough staff to keep people safe, although some people and staff felt there were not enough to spend meaningful amounts of social time with people. There were systems to review staffing levels and ensure they remained safe. The provider had robust recruitment systems to help protect people from the risk of being cared for by unsuitable staff.

Staff obtained people’s consent before carrying out care tasks. Where people did not have the capacity to consent, the provider confirmed this by carrying out capacity assessments and involved families and other professionals involved in people’s care to help ensure decisions made on their behalf were in their best interests.

The provider gathered information from a variety of sources to help staff keep up to date with current research and best practice. Staff had access to the training, supervision and support they needed to carry out their roles effectively.

People were able to choose from a variety of suitable, nutritious food and drink that met their needs. Staff monitored people’s weight and other health indicators when needed, using the data to inform them when they needed to support people to access health services. People had regular acc

We carried out an unannounced comprehensive inspection of this service on 7 January 2016 and a breach of regulation was found. This was because people were at risk of poor care as records were not maintained appropriately. Additionally, the providers’ own quality assurance systems had failed to identify this was an area that required improvements.

We also made a recommendation regarding activities for people who used the service. People told us and we saw there were some activities on offer, but the majority of people we spoke with told us they were not enough activities that suited their preferences and they were ‘sometimes bored.” This is an area we will look at during our next full comprehensive inspection of the service.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach described above and the recommendation we made.

We undertook a focused inspection on the 30 June 2016 to check they had followed their action plan and to confirm they now met legal requirements. This inspection was unannounced.

This report only covers our findings in relation to these requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Orchard House on our website at www.cqc.org.uk

Orchard House Nursing Home provides personal and nursing care for older people many of whom are living with dementia. It can also provide end of life care to people. The home can accommodate up to 44 people. At the time of our inspection 37 people were living at the home.

The service did not have a registered manager in post, although it is required to do so. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The registered manager had left the service in November 2015, the provider had recruited a new manager but they were still in their probationary period. The group operations manager told us that once the manager had completed their probationary period successfully they would then apply to become registered with the CQC.

During our focused inspection we found the provider had followed their action plan. The provider had introduced new care plan records and was in the process of transferring all information from one system to the other. Care plans and risk assessments were being reviewed regularly so they reflected people’s current needs.

Sufficient action has been taken to meet the legal requirements made at the last inspection, although we need to see consistent improvements over time before we are able to change the rating of this service from ‘requires improvement’.

The inspection took place on the 7 January 2016 and was unannounced and out of hours, we started the inspection at 6 am. The last inspection of this service was on the 18 June 2014. At that inspection we found the service was meeting all the regulations we assessed.

Orchard House Nursing Home provides personal and nursing care for older people many of whom are living with dementia. It can also provide end of life care to people. The home can accommodate up to 44 people; at the time of our inspection 36 people were living at the home.

The service did not have a registered manager in post, although it is required to do so. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The registered manager had left the service in November 2015, and the provider was currently in the process of recruiting to the post.

We found the provider did not always operate effective governance systems to monitor, assess and record the needs of each person using the service. The documentation regarding risk assessments and care plan reviews was not always signed or dated, so there was no way of establishing if the information was up to date. Also information contained in people’s care plans particularly about their life histories, was variable so staff may not always be able to find reference points when talking with people particularly if the person had dementia.

We identified a breach of the Health and Social Care (Regulated Activities) Regulations 2014 during our inspection in relation to good governance. You can see what action we have told the provider to take at the back of the full report.

Although the provider had some arrangements to meet people’s social and recreational needs, most people told us they did not have enough social and recreational activities. We have made a recommendation about the opportunities available to people using the service to have meaningful leisure and recreational activities that reflect their interests.

People told us they felt safe living at Orchard House. The provider had ensured there were sufficient staff on duty to meet people’s needs. Staff were knowledgeable about what they needed to do if they suspected anyone was at risk of harm.

Staff were knowledgeable about people and how to care for them. Staff received adequate training to meet people’s needs. We observed staff to be kind and caring. They ensured people retained their privacy and dignity when personal care was provided. The service was able to provide end of life care where people developed these needs.

People were asked for their consent prior to care being provided. If people were unable to give informed consent, the provider worked within the framework of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). DoLS is a way of make sure people are only deprived of their liberty in a correct and safe way. Staff had received training and were aware how to address issues if they arose.

People were encouraged to maintain good health. They had access to healthcare professionals according to their needs. People’s nutritional needs were assessed and monitored and people received a variety of meals according to their needs and choices. People received their medicines as prescribed by their GP.

Staff felt the management team provided them with support and took their views seriously. The service recorded accidents and incidents to monitor these and to try and prevent reoccurrences, and was open and transparent with agencies they worked with. People were encouraged to express their views about the service and the care they received for the provider to monitor the quality of service people received and to improve this where possible.

Below is a summary of what we found. We spoke with six people who used the service, two sets of friends and relatives, three members of staff, the business manager and the manager (known within the home as Matron). We looked at four sets of information about people who used the service and care home records. There were 38 people living at the home on the day of our inspection.

If you want to see the evidence supporting our summary please read the full report.

We considered our inspection findings to answer five questions we always ask:

• Is the service safe?

• Is the service caring?

• Is the service responsive?

• Is the service effective?

• Is the service well led?

Is the service safe?

Care plans showed that people’s needs were identified and met. These plans were regularly reviewed and updated so that they were meeting people’s current needs. Any risks were assessed and reviewed regularly to ensure people’s safety was promoted whilst ensuring their independence.

People were cared for in an environment that was kept clean and hygienic. Staff knew how to maintain good standards of cleanliness and hygiene within the home to reduce the risk of cross infection, as they had received appropriate training to do so.

The Care Quality Commission monitors the operation of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS). We saw staff had received training and that the home knew how to make a referral to the local authority if a DoLS assessment was required. This could help to ensure that people’s human rights were properly recognised, respected and promoted.

Is the service caring?

People we spoke with were positive about the care provided at Orchard House. Comments included, “staff are perfect, can’t get better than that”. Another person told us “couldn’t be better, it’s like the Ritz”. A relative told us, “I have recommended it to someone who is living here now”.

During our inspection we observed friendly and kind interaction between staff and people who used the service. Staff spoke with people respectfully and took time to sit and listen. People that needed additional support moving around the home were not rushed or hurried.

Is the service responsive?

We found staff continually monitored people’s condition and where necessary sought advice and assistance from other community based health and social care professionals.

The service had a complaints policy and procedure. People we spoke with told us they knew how to make a complaint if there was something that they were unhappy with. The home sent out surveys for people who used the service and their relatives and other stakeholders to comment on the care provided by the home. When people had made a complaint or raised any issues, senior staff took appropriate action to investigate and resolve the issues to people’s satisfaction.

There was some choice of activities available for people who used the service. However, people were not routinely given choices of social and recreational activities that suited their needs and interests.

Is the service effective?

People’s specific needs were taken into account and there was guidance and instructions for staff on how these should be met. People’s care plans were reviewed regularly and any necessary changes made. In this way people were receiving care that was appropriate to their needs.

The information that related to people who used the service was up to date, accurate and well ordered. We noted however that information that pertained to staff needed to be ordered in a way that would make it more accessible to navigate.

Is the service well-led?

The service had a registered manager who knew the service well. The service had quality assurance systems in place. We saw records that showed any issues identified were addressed promptly. As a result the quality of the service was continuingly improving.

Regular audits of the care plans and risk assessments were carried out to help ensure that people received good quality care at all times. There were systems in place to make sure staff learnt from incidents and accidents and other untoward events.

Staff were observed to speak with people in a kind and caring manner seeking their permission to provide care in accordance with the person's wishes. Where a person lacked capacity to consent to treatment a general practitioner and family members had been involved to ensure people's best interests were represented. One person we spoke with said '' they (the staff) know me so well they don't have to ask me, they know exactly what I need.''

People told us they had been involved in discussions about their care and support. We spoke with people using the service who said'' I am allowed to organise my own day.'' A relative we spoke with told us ''I don’t have to worry anymore. I know my mother will be well looked after. If I ask for something to be done I can be sure it will be done by the next time I visit.''

Medicines were safely and securely stored and appropriately administered.

There were effective recruitment procedures in place so that people could be confident they were cared for by appropriately qualified and trained staff.

Records were accurate and fit for purpose and stored securely to ensure confidentiality. Maintenance records were found to be up to date to ensure a safe environment for staff and people using the service.

People we spoke with told us that they were happy with the care that they receive. One person told us “The staff are very good”.

People told us they were given opportunities to express their choices and to make decisions in their daily lives. We observed that staff were aware of people’s preferences and routines so they could support people in their daily lives.

There were effective quality assurance and quality monitoring systems in place; these were used to seek the views of people using the service and to measure success in meeting the aims, objectives and statement of purpose of the home.