Archived: OSJCT Buckland Court

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service failed to improve the safe management of medicines. Repeated errors were found, and the provider remains in breach of legal requirements for safe care and treatment.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At the last inspection, the provider did not consistently demonstrate a proactive, positive safety culture based on openness and honesty. Lessons were not always learned to embed good practice. While a system existed to record and report incidents and accidents, these were not consistently reviewed or acted upon by the registered manager.

During our most recent visit, we observed some improvements, including shared learning through team meetings, feedback, and reflective practice. However, repeated medication errors where found. This shows that while some progress has been made, further work is required to ensure medicines are managed safely and effectively.

At our previous inspection, people were not consistently supported to take positive risks, particularly in relation to accessing the community. We found that individuals had limited opportunities to leave the care home for trips or activities outside. People told us they had not been supported to go out, which restricted their independence and choice. This demonstrated that the provider was not actively assessing or managing risks associated with people spending time in the community, limiting their ability to maintain social connections and engage in meaningful activities.

During this inspection, some improvements had been made. For example, people had been supported to participate in community activities, such as attending a remembrance service and a ‘ladies’ night at a sister home. This meant that although some progress had been made, further work was required to fully involve people in managing risk in relation to people being supported to leave the care home.

During our last inspection we found the provider did not consistently assess, monitor or mitigate risks relating to the safety of the environment.

During this inspection the provider had now detected and controlled potential risks in the care environment. For example, we observed that all windows were fitted with appropriate window restrictors, and additional plug sockets had been installed where required. The service had completed a fire risk assessment in 2024, which identified actions such as replacing fire doors. All these actions had now been completed. This meant people were now protected from the risk of harm.

At our previous inspection, the provider did not assess or manage the risk of infection. They did not detect and control the risk of infection spreading or share concerns with appropriate agencies promptly.

During this inspection, we observed improvements in both the maintenance and cleanliness of the home. Malodour had reduced following the replacement of flooring throughout the care home. Furthermore, the provider had introduced deep-clean schedules. However, these were not consistently completed. Windows were also visibly dirty, and the provider had not followed up on a missed visit by the window cleaner. This meant that although improvements had been made, the service needed further time to embed good practice and ensure cleanliness was maintained and the risk of infection was reduced.

At our last inspection, the provider did not ensure that medicines and treatments were safe and met people’s needs. During this inspection, the registered manager and area manager told us that regular medication audits had taken place. However, we found repeated medicines errors which the auditing had not picked up on. For example, one person’s medicines had been changed by their doctor on discharge from hospital. While these changes were booked in correctly by a member of staff, colleagues had not read the updated instructions and administered the incorrect quantity for two days. This meant the provider could not assure themselves that people were receiving the right medication and the right time.

Other issues identified by leaders through audits included medicines not always being administered in line with the provider’s policy, the medicines trolley had not always being secured safely, and the medicines fridge not kept clean. These concerns had been addressed by the manager. However, the risks had not been fully mitigated to assure the provider that they would not happen again. This meant further work was required to ensure medicines were managed safely and effectively.