Orchard House

Orchard House is a residential care home providing personal care to up to 15 people. The service provides support to people mainly living with Huntingdon’s Disease. At the time of our inspection there were 12 people using the service. The service comprised of one large adapted building and a bungalow in the grounds.

People’s experience of using this service and what we found

People told they were happy living at the service. Relatives told us they thought their loved ones were safe and well cared for.

Potential risks to people’s health and welfare had been assessed and staff were provided with guidance to mitigate the risks. Accidents and incidents were analysed to identify patterns and trends with action taken to prevent them happening again. The manager worked with the local safeguarding authority when concerns were raised to keep people safe.

Care plans contained information about people’s choices and preferences, they had been reviewed when people’s needs had changed. People’s health needs were assessed and reviewed using recognised tools following government guidance. People received their medicines as prescribed and were supported at the end of their lives.

People were supported by enough staff who had been recruited safely. Staff had received training appropriate to their role. Competency checks and supervisions were completed to support staff with their practice and knowledge. The provider had a complaints policy in place, this had been followed when complaints had been received.

Checks and audits had been completed and had been effective in identifying shortfalls. Action had been taken to rectify the shortfalls.

People were supported to have a balanced diet and were supported to eat their meals safely. People were referred to healthcare professionals when their needs changed, and guidance was followed.

People were supported to have maximum choice and control of their lives and staff supported support them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 17 September 2019). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 5 and 6 September 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, good governance, safeguarding, person centred care and notifying CQC.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective, Responsive and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.

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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Orchard House is a residential care home providing personal care to 15 people mainly living with Huntingdon’s disease at the time of the inspection. The service can support up to 15 people in one adapted building and a bungalow in the grounds.

People’s experience of using this service and what we found

People told us or indicated they felt safe living at the service. However, potential risks to people’s health, welfare and safety had not been consistently assessed. Staff did not have guidance to mitigate risk and keep people safe.

Incidents and accidents had been recorded but had not been analysed to identify patterns and trends. Incidents involving behaviour that may be challenging had not been discussed with the local safeguarding authority. The registered manager had not notified the Care Quality Commission of incidents within the service as required.

Medicines had not been managed safely. Staff had not followed guidelines when administering medicines. People’s health needs had not been assessed using recognised tools and following good practice guidance. Care plans did not always reflect the care being given.

Checks and audits had been completed. However, they were not robust and effective in identifying the shortfalls found at this inspection. People and staff had been asked their opinions on the service. The actions taken in response to any concerns or suggestions had not been clearly recorded, this is an area for improvement.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, improvements in the recording of decisions was required.

People were given a choice of meals and snacks to keep them as healthy as possible. Staff knew people’s choices and preferences and people told us they were supported in the way they preferred.

People were treated with dignity and respect, staff supported them to remain as independent as possible. People’s health was monitored, and they were referred to health professionals as required. People‘s end of life wishes were recorded, staff worked with other health professionals to support people at the end of their lives.

People were supported by staff who were recruited safely, were appropriately trained and received supervision to continue their development. People were protected from the risk of infection.

The registered manager had recorded and investigated complaints following the provider’s policy. People and relatives told us that the registered manager was approachable, and staff told us they felt supported.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Good (Published 25 March 2017).

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Responsive and Well Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Orchard House provides a specialist service for people diagnosed with neuro-disabilities, specifically Huntington’s disease. There were 12 people living at the service at the time of inspection. They had complex communication and mobility needs.

The service is a large detached house and a bungalow in a residential area of Herne Bay. Some people had lived at the service for a long time and were becoming increasingly frail. Due to the deterioration in their condition the amount of personal care and support they needed had increased. Other people were more independent, able to make decisions for themselves and go out independently.

There was a registered manager working at the service and they were supported by an assistant manager. They were also the registered manager of another service close by. 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 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 last inspected in January 2016 when it was rated requires improvement overall with five breaches of regulation identified. The breaches of regulations related to staff training, recruitment and supervision, staff not having the guidance they needed to keep people safe, care plans not being updated and audits at the service not identifying the issues found at the inspection. There were improvements found at this inspection. The registered manager had made changes based on the last inspection report and a recent inspection at another nearby service that they managed.

On the day of the visit the registered manager supported us throughout the inspection. The registered manager had been in charge at the service for a long time. They knew people and staff well. People’s care plans had been updated with them or their loved ones, they showed the support people needed, what was important to them and how they preferred to be supported. Staff were now continuing to review and update the plans on a regular basis.

Risks to people had been assessed and staff now had detailed guidance relating to minimising risks and keeping people safe. The safety of the premises was maintained by regular and routine checks of the environment and equipment.

Staff were now recruited safely using all the checks required and had access to training which enabled them to support people confidently. Staff had more regular one to one meetings with their line manager. There were enough staff to meet people’s needs.

The registered manager and provider had improved the auditing systems they used. Audits were completed regularly and action was taken to address any shortfalls. Opinions and feedback about the standard of care were sought from people, loved ones and visitors, any issues were addressed and the results of the feedback were shared.

Staff knew people and their families well; they had developed positive and caring relationships. Staff changed the way they interacted for each person but all interactions were empathetic and caring. People’s family and friends could visit whenever they wanted and told us they felt like they were all part of one big extended family.

Staff supported people in a way which respected their dignity and privacy such as knocking on people’s doors and giving them private time with their families. Staff talked to people about what was happening and what they were doing at all times. People were supported to retain their independence for as long as possible.

Staff knew how to recognise and respond to abuse. The registered manager was aware of their responsibilities regarding safeguarding and staff were confident the registered manager would act if any concerns were reported to them.

People were offered a selection of food which was tailored to their needs, following guidance from the speech and language team. Staff supported people to eat in a gentle and encouraging way. Records were maintained of each person’s intake of food and fluids.

Staff were effective in monitoring people's health needs and seeking professional advice when it was required. People received their medicines safely and when they needed them and they were monitored for any side effects. The temperature in the area where medicines were stored was now checked and recorded daily.

People had a choice of activities and told us they could try anything. There was a mixture of trips out and activities in the service. People were encouraged to maintain their interests and continue to try new things.

Staff told us how they supported people to make their own decisions and choices. Staff had received training on the Mental Capacity Act (MCA) 2005. The MCA provides the legal framework to assess people's capacity to make certain decisions, at a certain time.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The requirements of DoLS were met.

There was a complaints policy in place and staff knew what to do if anyone complained. When complaints were made they were documented and investigated in line with the provider’s policy. The CQC had been informed of any important events that occurred at the service, in line with guidance.

Staff and relatives told us that the registered manager and provider were accessible and approachable. Staff were passionate about their roles and felt valued by the service. Staff understood the need for confidentiality and records were stored securely.

The registered manager and provider had links to the Huntington’s disease association and ran a local support group. They also worked closely with the specialist medical team for Huntington’s disease and shared information from these professionals with the staff team and people’s families.

Orchard House is situated in a residential area of Herne Bay. It provides a specialist service for people diagnosed with neuro-disabilities, specifically Huntington's Disease. The service comprises of a large detached house where 10 people can live and a separate three bedded bungalow. At the time of the inspection there were nine people living in the main house and the extra room was used for people who needed respite care. There were two people living in the bungalow and the third room was used for respite care. Some people had lived at the service for a long time and were becoming increasingly frail. Due to the deterioration in their condition the amount of personal care and support they needed had increased.

The care and support needs of the people varied greatly. There was a wide age range of people living at the service with diverse needs and abilities. Some people had complex communication and mobility needs. Some people were able to make their own decisions about how they lived their lives. They were able to let staff know what they wanted and were able to go out on their own.

The main house was set out over two floors. The first floor could be accessed by stairs or a passenger lift. On the ground floor were communal areas and bedrooms. Each person had their own bedroom which contained their own personal belongings and possessions that were important to them.

There was a registered manager working at the service and they were supported by a deputy manager. They were also the registered manager of another service close by. 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. On the day of the visit the registered manager, staff and the provider supported us throughout the inspection.

The registered manager had been in charge at the service for a long time. They knew people and staff well. The deputy manager spent more time at the providers other service, managing it on a day to day basis.

The registered manager and some staff knew how the Mental Capacity Act (MCA) 2005 was applied to ensure decisions made for people without capacity were only made in their best interests. They considered people’s abilities to give consent to complex decisions and held best interest meetings when people were unable to give consent. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have been agreed by the local authority as being required to protect the person from harm. DoLS applications had been made to the relevant supervisory body in line with guidance.

The care and support needs of each person were different and each person’s care plan was personal to them. Parts of the care plans recorded the information needed to make sure staff had guidance and information to care and support people in the safest way. People indicated they were satisfied with the care and support they received. However, some parts of the care plans did not record all the information needed to make sure staff had guidance and information to care and support people in the way that suited them best and kept them safe. Potential risks to people were identified but full guidance on how to safely manage the risks was not always available. This left people at risk of not receiving the interventions they needed to keep them as safe as possible.

Staff were caring and respected people’s privacy and dignity. There were positive and caring interactions between the staff and people and people were comfortable and at ease with the staff. When people could not communicate verbally staff anticipated or interpreted what they wanted and responded quickly. Staff were kind and caring when they were supporting people. Some people were unable to communicate using speech. The way that people communicated was not recorded in their care plans to guide and inform staff. Information was not presented in ways people found meaningful and accessible.

People were supported to have a nutritious diet. People, because of the condition they were living with, required a lot of extra calories throughout the day. Staff made sure people received all the food and drink and that they needed. Care and consideration was taken by staff to make sure that people had enough time to enjoy their meals. Meal times were managed effectively to make sure that people received the support and attention they needed.

The staff were effective in monitoring people’s health needs and seeking professing advice when it was required. People received their medicines safely and when they needed them and they were monitored for any side effects. When people needed medicines on a ‘when required’ basis there was guidance so that they were given consistently. The room temperature where the medicines were stored was not consistently checked to make sure the medicines remained effective. People’s medicines were reviewed regularly by their doctor to make sure they were still suitable.

People felt safe in the service. Staff understood how to protect people from the risk of abuse and the action they needed to take to report any concerns in order to keep people safe. Staff were confident to whistle-blow to the registered manager if they had any concerns and were confident appropriate action would be taken. The registered manager responded appropriately when concerns were raised. The registered manager followed clear staff disciplinary procedures when they identified unsafe practice.

Accidents and incidents were recorded and appropriate action had been taken. The events had been analysed to look for patterns or trends to prevent further occurrences.

A system to recruit new staff was in place. Not all the safety checks had been completed before staff started to work unsupervised with people. There were sufficient numbers of staff on duty throughout the day and night to make sure people were safe and received the care and support that they needed. There was enough staff to take people out to do the things they wanted to.

New staff had induction training but this was not monitored. Staff were not checked to make sure they were competent before they started working on their own with people. New staff did shadow experienced staff and said they did not work unsupervised until they felt ready.

Core training and more specialist training was provided but not all staff were up to date with parts of the training and some staff had not received specialist training to meet people’s specific needs. However, staff did have a good knowledge about people’s conditions.

Staff fully understood their roles and responsibilities as well as the values of the service. Staff were receiving support from the registered manager through one to one meetings but the frequency of the meetings were not in line with the provider’s supervision policy. Staff did not have the opportunity to regularly privately discuss any issues, their performance and identify any further training or development they required. Yearly appraisals were being held to make sure staff had the opportunity to review the previous year and set work based goals for the following year.

There was a complaints procedure available. The complaints procedure was not produced in an accessible or easy read format that may be more suitable for people’s needs.

There were quality assurance systems in place. Audits and health and safety checks were carried out but some shortfalls had not been identified and action had not been taken. The registered manager had formally sought feedback from people their representatives and staff about the service. Their opinions had been captured and analysed but there was no action plan to show how the provider intended to address all issues and suggestions to drive improvements within the service.

People, staff and relatives told us that the service was well led and that the management team were supportive and approachable and that there was a culture of openness within the service.

We found a number of breaches 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 this report.

People told us that they were asked for consent before any care or treatment took place and their wishes respected.

We found the home to be clean and tidy and free from unpleasant odours. There was a system in place for infection control to protect people from the risk of infection.

Staff recruitment records showed that new staff had been thoroughly checked to make sure they were suitable to work with vulnerable people. Systems were in place to monitor the service that people received to ensure that the service was satisfactory and safe. People told us they did not have any complaints but would not hesitate to speak to the manger or staff if they had any concerns.