Swindon care home ordered to improve over medicines mix-up

The Orchards Residential Home, located on Perrys Lane, was assessed between November 27 and December 19, 2025, after concerns were raised about end-of-life care, staff training, and whether residents were treated with dignity and respect.

At the time, the home was supporting 42 people, including some living with dementia.

Its overall rating is now Requires Improvement, with a similar rating for the Safe and Well-Led categories, though it is considered Good for being Responsive, Caring, and Effective.

The main area of concern focused on the management and administration of medicines.

The report revealed that medicines were not always managed safely, with one person receiving them in a concealed way known as ‘covert administration’ for about a month, despite it being unnecessary.

This mistake was not picked up by the home’s management.

Inspectors also found that a person’s Medicine Administration Record noted they had medicine allergies, but did not specify which medicines they were allergic to.

In some cases, records did not clearly show that residents received their medicines as prescribed, and at times it was unclear whether medicines had been administered at all.

The systems that the home used to check and monitor medicines, such as audits, were found to be ineffective.

The assessment led to The Orchards breaching a legal regulation concerning the safety of care and treatment provided, specifically relating to medicines.

Further issues identified included unexplained gaps in the administration of prescribed medicines.

Staff could not explain why a medicine described as ‘use as directed’ had not been given.

Inspectors also found that some medicine care plans contained inaccurate or vague information. For example, one resident diagnosed with epilepsy had a care plan telling staff to give ‘rescue’ medicine if it was prescribed, but the person had never been prescribed such medicines.

This lack of accurate, personalised information increased the risk of mistakes.

Storage of medicines was also found to be problematic.

For the previous three to four months, the temperatures of the medicine fridge had been outside the recommended range, but no action was taken by staff.

Medicines in liquid form sometimes did not have the date they had been opened, raising the possibility that expired medicines could be given out.

Despite these concerns, the report noted some positive aspects.

Staff were found to have an appropriate level of training and supported residents kindly and with compassion.

Residents appeared comfortable around the staff.

The home was described as clean and well maintained, and there were clear policies and procedures for staff to follow.

Residents themselves expressed satisfaction with life at The Orchards.

One resident said: “I like it because everybody is so very friendly and very helpful. I have made friends here.

“There is always somebody to talk to and we take meals together. I’m definitely happy with everything here.”

Another said: “They look after you and take care of you. It’s a nice place.”

Residents also said they knew how to raise concerns if needed and felt supported by regular staff.

Most people agreed there were enough staff, though one suggested staffing could be improved at weekends. Food and drink choices at mealtimes were also praised.

Residents spoke warmly about the manager, with one saying: “I know the manager [name] is very nice and we have a laugh. She makes time for me, and I know I could talk to her if there was a problem.”

Another said: “I know her well, she is kind and listens to you.”

In response to the findings, the manager said they had made changes, including training staff on safe processes, buying a new thermometer for medicine storage, and introducing new documents.

A Buckland Care spokesperson said: “We welcome the CQC’s feedback for The Orchards and are pleased that the home continues to be rated Good in three out of five key areas.

“The issues identified around medication management and leadership were taken very seriously and were addressed immediately following the inspection.

“We are also pleased to confirm that a new experienced Home Manager and Deputy Manager are now in post, providing strong, stable leadership for the team and ensuring high standards of care and safety for residents.

“We remain fully committed to delivering safe, effective and compassionate care and would welcome the opportunity for the CQC to return and re-inspect at the earliest opportunity so that we can regain our overall Good rating.”