OSJCT Coombe End 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 changed to good. This meant people were safe and protected from avoidable harm. The provider had identified shortfalls in the support for people to manage their medicines and taken effective action to make improvements.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents and accidents were recorded and reviewed by managers to ensure action to reduce the risk of a repeated incident were taken. Learning from incidents was shared with all staff to ensure they understood any changes to the way they needed to support people. Information from incidents was included in staff handover records, to ensure staff had key information at the start of their shift. Managers could access these systems remotely, meaning senior managers could maintain oversight of what was happening in the service.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Incidents and accidents were recorded and reviewed by managers to ensure action to reduce the risk of a repeated incident were taken. Learning from incidents was shared with all staff to ensure they understood any changes to the way they needed to support people. Information from incidents was included in staff handover records, to ensure staff had key information at the start of their shift. Managers could access these systems remotely, meaning senior managers could maintain oversight of what was happening in the service.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People said they felt safe living at Coombe End Court, with comments including, “Oh yes, I feel perfectly safe. I have never doubted anything here” and “Yes, I am looked after. It is all good”. Staff demonstrated a good understanding of their safeguarding responsibilities and said they completed regular safeguarding training. Staff were confident managers would take appropriate action if they reported safeguarding concerns but were aware how to raise these concerns outside of the organisation if they needed to.Where appropriate staff had applied to the local authority for Deprivation of Liberty Safeguards (DoLS) authorisations. The manager had a record of all DoLS applications that had been made, including details of any conditions to the authorisations.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People told us they felt safe when receiving care. Risks to people’s health, safety and welfare had been assessed and plans developed to manage those risks. Staff demonstrated a good understanding of the risks people faced and how to support them safely. Staff told us risk management plans were regularly reviewed and updated as people’s needs changed. Staff had immediate access to updated plans through the electronic care planning system and were notified of any changes. Staff now kept contemporaneous records of the support they provided to support people to manage risks, including ensuring people were regularly re-positioned and recording well-being checks.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People told us the home was well maintained and secure, with one person commenting “I feel safe living here. When the night staff are on, I feel safe and that there are no dangers for us”. The provider assessed the service for risks and took action to ensure people, staff and visitors remained safe. Equipment, such as fire systems, water systems and hoists had been regularly serviced and tested to ensure they were safe. Staff told us action was taken quickly when repairs were needed. The provider now had effective systems to ensure the security of the building at night, which records demonstrated staff followed consistently. Doors to cupboards used for storage of chemicals were now kept locked when not in use. External doors were alarmed, to alert staff of anyone trying to leave the building without support or of any intruders.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People felt there were enough staff available and said staff generally responded quickly when they requested assistance. Comments included, “There are plenty of people about, I think there are probably enough carers” and “The [staff] response time is quite good. There is always someone around”. People said staff had the right skills and knowledge to meet their needs. Required pre-employment checks had been completed for staff before starting work. New staff received an induction, including opportunity to shadow experienced staff until they were confident. Staff told us they felt there were now enough of them to provide safe careand said they received regular training, supervision and an annual appraisal.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People told us the service was always kept clean. We observed the home was now cleanand staff following good infection prevention and control practice, to help keep people safe. Staff said they had completed infection prevention and control training and had access to all the equipment they needed.

The provider had not always made sure that people were supported to take the medicines they were prescribed. The service had experienced 28 medicines errors in April 2025, including 15 incidents in which people were not supported to take their prescribed medicines.The provider took appropriate action to ensure people did not experience harm, including consultations with GPs or the local out-of-hours service. The errors were reported to the local safeguarding team and the provider worked with their supplying pharmacy to make improvements. Staff had received additional training and competency checks to ensure they had the knowledge and skills to support people safely. Additional checks of medicines had been introduced, and the provider had brought in experienced staff from another of their services to help embed the new systems. This had resulted in an 82% reduction in errorsduring May 2025, with only 5 errors identified by the provider, all of which related to recording rather than errors in the medicines people received. The provider had action plans in place to reduce errors further and ensure improvements were sustained. Medicines administration records we checked for the week of the site visit had all been fully completed, with people supported to take the medicines they were prescribed. People told us they were happy with the support they received with their medicines and were able to get additional pain relief when needed.