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Inspection Summary

Overall summary & rating


Updated 10 December 2019

About the service

Osborne House is a modern, purpose built nursing and residential care home. The service was providing personal and nursing care to 52 people aged 65 and over at the time of the inspection.

The service can support up to 74 people over three floors, each of which has separate facilities. The top floor specialises in providing residential care to people living with dementia and nine people were on this floor. The middle floor provides nursing care and had 21 people receiving support. The ground floor provides general residential care and had 22 people living there at the time of the inspection.

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

We looked at the whole service during the inspection; the care and support given to people on the ground floor and top floor was sufficient to meet people’s needs. The outcomes of our report mainly reflect the care and support practices of the nursing unit on the middle floor. Throughout the report we have referenced where our judgement is specific to the nursing unit. All other judgements relate to the whole service.

Nursing unit

Insufficient numbers of experienced and competent staff had impacted on all aspects of the care being delivered. There was a lack of effective organisation amongst the senior staff, which meant new and inexperienced staff were working without sufficient guidance and support.

Care records were not completed in a consistent manner. Some records were not up to date and documentation was not fully completed. Staff said they did not have time to read the care records.

People’s privacy and dignity was not promoted through staff practice. The care and support delivered to people were task based and did not meet their needs. People were not being supported to wash or bathe on a regular basis which meant their skin integrity was put at risk and they appeared unkempt.

Staff lacked the knowledge and skills to effectively manage the behaviours of people living with dementia. This put people and others at risk of harm.

All three units

The recording and administration of medicines was not managed appropriately in the service. People did not always receive their medicines as prescribed by their GP.

The induction, supervision and training programme for staff was not robust and did not adequately enable them to carry out the duties they were employed to perform. The provider did not monitor this which meant people were at risk of being cared for by staff who lacked the knowledge, competency and skills to meet their needs.

The lack of effective leadership, oversight and management meant the quality assurance and monitoring processes within the service were not used to drive improvement. The assessment, monitoring and mitigation of risk for people with regard to basic care needs such as medicine management, bowel care, personal hygiene and pressure care was not carried out effectively. This meant people's health and safety was put at risk.

We received positive feedback from people and relatives on the residential and dementia units about their care and support. People on these two units were treated with dignity and respect.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at

Rating at last inspection

The last rating for this service was good (published 29 May 2019).

Why we inspected

The inspection was prompted in part by notification of a specific incident. During which poor care practices were observed. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management of risks to people who may experience distress or anxiety and staff approach to safety during personal care. As a result we undertook a focused inspection to review the Key Questions of Safe and Well-Led only.

We reviewed the information we held

Inspection areas



Updated 10 December 2019

The service was not safe.

Details are in our safe findings below.



Updated 29 May 2019

The service was effective.

Details are in our Effective findings below.



Updated 29 May 2019

The service was caring.

Details are in our Caring findings below.



Updated 29 May 2019

The service was responsive.

Details are in our Responsive findings below.



Updated 10 December 2019

The service was not well-led.

Details are in our well-led findings below.