Orchard Court

A new nominated individual had taken over the care home in November 2025. The provider’s systems did not ensure medicines were managed safely. Records did not demonstrate people received their medicines in line with the prescriber’s instructions. We found some medicines were crushed and were unsafe to do so. Staff did not escalate when medicines errors had occurred for advice to be sought and investigations undertaken. The provider did not have records to demonstrate staff competency to administer medicines safely had been assessed.

Systems were not established to ensure staff were equipped with the required training for their role. Parts of the environment were not well-maintained or cleaned effectively and staff did not always promote best practice with infection prevention and control. Whilst essential checks of fire equipment were in place, the service’s fire risk assessment had not recently been reviewed and there were some outstanding actions from the last assessment. The provider had not ensured contemporaneous records were completed including accurate completion of daily records and consistent information within people’s care records. Care records also lacked person-centred detail to guide staff practice. People had not always been included in discussions about their care and afforded the opportunity to say what they wanted.

The provider was passionate about making improvements at the service and had a programme of refurbishment and had already started taking actions to address elements of the environment including fixing the roof and installing a new kitchen. There was a new manager in post. Although staff hadn’t received regular supervisions, they felt supported, and told us the manager was approachable and visible. The management team were responsive to the feedback and started to take corrective actions including a detailed check of medicines, arranging staff training sessions and organising risk assessments for parts of the premises.

We found the provider was in breach of legal regulations relating to safe care and treatment and governance of the service.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.We have also asked the provider for an action plan in response to the concerns found at this assessment.