The inspection took place on 26 and 28 February and 05 March 2018. This first two days of the inspection were unannounced and the third day was announced.

The last inspection of the service was carried out in August 2015 and at that time the service was rated as good.

Orchard Nursing is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Orchard Nursing is registered to provide accommodation, personal and nursing care for up to 31 people. There were 26 people living at the service at the time of the inspection.

The service does not have a registered manager, the last registered manager left in November 2017. 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 has been appointed and they have applied to CQC to become the registered manager.

At this inspection we found breaches of the Fundamental Standards of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were related to Regulation12 Safe care and treatment, Regulation 15 Premises and equipment, Regulation 10 Dignity and respect and Regulation 17 Good governance.

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

Parts of the premises and equipment used by people were unsafe. Fire exit routes were obstructed and call bell cords in bathrooms and toilets were tied up out of people’s reach. Rooms containing hazards which posed a risk to people’s health and safety were not secured. At the time of inspection fire exit routes were cleared, call bells were made accessible to people and rooms containing hazards were secured.

People were placed at risk of the spread of infection. Items of equipment used to help people with their comfort and mobility were unclean. This included easy chairs, hoists and stand aids. Clinical waste had not been disposed of in line with safe infection control procedures. At the time of the inspection equipment was cleaned and clinical waste disposed of appropriately.

People were placed at risk of receiving ineffective care. Supplementary care records including fluid balance and positional change charts were not accurately completed to reflect the care and support people received. In addition the records did not include important information about people’s needs. The records were amended at the time of inspection to include the required information about people’s needs and the expected outcome.

People’s dignity was not always respected. People were left waiting for assistance to use the toilet which caused them unnecessary stress and discomfort. Staff left people waiting whilst they focused on tasks rather than responding to people’s personal care needs. Despite this we observed examples where staff provided personal care to people in a dignified way.

Checks to monitor the quality and safety of the service were not always effective. There was a lack of robust checks on the environment and cleanliness of equipment which resulted in a failure to identify and mitigate risks to people’s health, safety and wellbeing. There was also a failure to carry out regular checks on care records and staff practice resulting in people being placed at risk of receiving ineffective care which was not responsive to their needs.

We have made a recommendation about activities and the environment. Throughout the three days of inspection we observed a lack of activities for people to take part in. The majority of people were sat in lounges either watching TV or asleep and staff did not offer them any f

This was an unannounced inspection, carried out on 11 August 2015.

Orchard Nursing accommodates up to 31 people. The service provides single bedrooms, shared lounges and dining rooms and there are gardens for people to use. Parking is available directly outside the building and public transport links are close by.

The service has had a registered manager since August 2011. 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 last inspection of Orchard Nursing was carried out in May 2013 and we found that the service was meeting the regulations we reviewed.

Information and guidance in relation to safeguarding people from abuse or the risk of abuse was readily available to staff. People were kept safe by staff who knew how to identify and respond to abuse. People felt safe and were confident about raising any concerns they had about their safety.

The recruitment of new staff was thorough and safe which ensured applicants were suitable to work in a care setting. Staff completed an application form, attended an interview and underwent a series of checks prior to them being offered a job.

Risk assessments were carried out and risk managements plans that were in place showed what actions staff should take to minimise the risk of harm and injury to people. There were sufficient staff to meet people’s needs safely. Medicines were safely managed and checks were undertaken to ensure the building and emergency equipment was checked regularly.

The service acted in accordance with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). This meant people who lacked capacity to make specific decisions were protected and authorisation was sought before people were lawfully deprived of their liberty. People’s consent was obtained prior to them receiving care and support.

Staff were supported within their roles and they received training relevant to the work they carried out, and the needs of the people who used the service. Staff told that they received a great deal of training and that they were always attending refresher courses to update their knowledge and skills.

People were offered a choice of food and drink and their dietary needs were understood by staff. Staff engaged with people whilst assisting them to eat and drink and they were patient in their approach. People who were at risk of malnutrition or who had specialist dietary needs received appropriate input from nutritional specialists and other relevant health professionals. The chef was knowledgeable about people’s dietary needs and prepared the right food and drinks for people.

People spoke positively about the care they received and were supported by staff that had good knowledge of their care and support needs. Care and support was planned around people’s choices and personal preferences. People were treated in a respectful and dignified manner and their care needs were met with kindness, consideration and patience.

People were listened to and involved in the planning of their care and support. People’s likes, dislikes, cultural, religious and spiritual needs were taken account of. Care plans and risks people faced were reviewed regularly and updated to reflect any changing needs. People and their family members had access to a complaints procedure and they were confident that any complaints they had would be listened to and acted upon.

The environment aided the orientation of people living with dementia. Photographs, coloured doors and pictorial signs were used so that people could recognise parts of the service such as bathrooms, toilets and their bedrooms. Period items such as pictures and ornaments were located around the service to help stimulate people’s memories and generate conversations from the past. Menus and activity programmes were available in picture format so that people could better understand them.

People, family members and staff spoke positively about the registered manager. They told us the registered manager was easily accessible, approachable and supportive. There was an open culture within the service and care was delivered in a positive environment.

Effective systems were in place to monitor and assess the quality of the service people received and to ensure that the service was safe. These included checks on care plans and medication and on practices such as infection control and health and safety. The service encouraged open communication with people who used the service, family members and staff. Surveys and regular meetings captured people’s views and recorded actions taken by the service in response to them.

We had previously inspected this service on 18 July 2012. We found areas of non compliance for which compliance actions were set. During our visit we found there had been improvements in the outcomes inspected.

We spoke with three people who used the service and their relatives. People told us that the care they had received had been delivered in a way that respected their privacy and dignity. Their comments included:

"I am very impressed with the whole atmosphere here".

"The staff are very kind, never impatient with me".

"I think it is great, I have nothing to worry about".

During our visit we saw evidence that care plans were detailed and people had been involved in planning their own care in line with their individual needs and wishes. We looked in detail at five care records of people using the service and saw that they were up to date and included relevant risk assessments.

Staff told us they felt well supported and had undertaken training to provide them with the required skills and knowledge to meet people’s needs including supporting people who had dementia.

The provider had systems in place to maintain and monitor the care and safety of people using the service.

Records were accurate and included appropriate information and documents. They were kept securely and could be located promptly when needed.

We used a number of different methods to help us understand the experiences of people living at Orchard Nursing. This was because some of the people using the service had complex needs which meant they were not able to tell us their experiences. We spoke individually with five of the people living there and with five visitors. We also spent time observing the support provided by staff.

The people living at Orchard Nursing told us that staff had always been respectful and polite. Their comments included, “couldn’t ask for nicer. They’re lovely” and “100 percent always polite.” They also told us that they had received the help and support they needed with their personal care and their health. Their comments included, “if you need help you get it” and “they help me.” Relatives expressed the same view telling us, “If anything is wrong they get the doctor” and that their relative was “always well looked after.”

All of the people we spoke with who lived at Orchard Nursing told us that they felt safe living there. One person explained, “They say talk to them about any little anxiety” and most of the people we spoke with knew how to raise any concerns they had.

We spoke with people who lived in the service. They told us that they were generally happy with the service provided and the care they received from staff.

Some comments made were;

"I like living here, things have got a lot better since we got a new manager she is lovely. The girls here work really hard always rushing around they don’t have time to stop",

“Staff here are great, there are some that I don’t like but that’s life you can’t like everybody but most of them are really kind and chatty” and

"I’d like more to do sometimes its ages before you see one of the staff, they try their best but don’t always have time ".

Relatives spoken with were positive about the support provided by the care workers. They told us that that they were made to feel welcome when they visited. One relative said they thought the care workers were reasonably well trained. Another said they thought the care workers “needs a bit of a refresher”. Another relative said that “the girls here are wonderful, they are so supportive and kind. They understand my mother and they have looked after her so well she’s got better since she moved in. It took time but they did a good job”.

We spoke to people who lived in the service. People's opinions of their involvement in the service and influence to change varied. All agreed that if they requested something such as to go to bed or get up this was accommodated. People told us that they were able to get up and go to bed at a time of their choosing. On occasions this could be delayed up to an hour as care workers were busy else where.

On the day of our visit we noted that one person had got up late and was offered a late breakfast. There were no arrangements in place for them to have the rest of their meals later in the day as a result they had all their meals breakfast, lunch and dinner within a 5 and half hour period. We noticed that there were 3 and half hours between lunch and dinner, with dinner being served at four pm. Two people we spoke with said that they would like their meal later, two others said that they "did not mind".

Relatives spoken with told us that they thought dinner should be later. Three people stating that their relative had eaten their evening meal much later than four pm before they moved into the service.

One person told us that care workers checked on them several times overnight. They were happy that this occurred but did not want this more than once or twice overnight as care workers "don't always close the door quietly and it wakes me up". They could not recall if they had ever been asked how many times they wanted to be checked on overnight.

Two relatives spoken with told us that they thought people were "well looked after", they also said that they had not seen their relatives care plan for sometime but would like too. Relatives also told us that they thought "more" going on in the service would help. One relative said "my mother does not come out of her room but nobody goes in to just sit and chat with her it would be nice if they could".