Osmund Court (Care Outlook)

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. This is the first assessment for this newly registered service. This key question has been rated 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 was in breach of legal regulation in relation to people’s safe care and treatment and medicines were not always managed safely.
 

This service scored 62 (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 understood how to report incidents and described receiving feedback after safeguarding or incidents, helping them learn from events. The service had introduced new logs for incidents, complaints and medicines as part of wider organisational improvement. People and relatives consistently described staff as responsive and attentive. Health professionals reported strong collaborative work, noting staff seek advice promptly and follow guidance to keep people safe.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. Systems that support safety through referral, admission and transitions required improvement. Pre‑assessments lacked sufficient detail, and important health risks were not always captured, as a result of this staff did not routinely identify health conditions requiring ongoing monitoring. Professionals gave examples of effective joint working and good rehabilitation outcomes, and relatives described continuity of care. However, inconsistent assessment meant staff were not always aware of key risks at admission, limiting their ability to plan safe care. The registered manager described challenges with ensuring appropriate information was shared with them. They told us they intended to follow up with key stakeholders and ensure staff had access to information to improve safe systems of care.

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. Staff understood safeguarding and their responsibilities. They received training and could identify signs of abuse, such as unexplained injuries or changes in behaviour. Staff felt confident raising concerns and described clear reporting routes. People repeatedly told us they felt safe with staff when being supported to use equipment such as hoists and stand aids, one person said, “I feel safe when they move me… they don’t rush.” Policies aligned with national guidance, and professionals described the culture as kind, compassionate and protective.

The service usually worked well with people to understand and manage risks. The service had a falls policy in place to guide on what to do in the event of an emergency. We identified some areas of risk management required improvement. The provider did not always monitor key health risks effectively. Staff relied heavily on handovers and verbal updates, and key information was shared through messaging apps or handwritten. Care plans did not always contain clear information about why monitoring was required, what staff should look for, or when concerns should be escalated. For example, some people were prescribed medicines for constipation relief, yet there was no accompanying guidance or baseline information to support staff in identifying deterioration or changes in bowel patterns, which increased the risk that emerging issues could go unnoticed. The service had not fully embedded structured tools such as bowel charts or fluid and nutritional monitoring records, despite these being necessary to support people at heightened risk. Whilst we have not identified incidences of harm at this assessment, shortfalls in the level of available information potentially meant people were not always protected from avoidable harm.
The registered manager told us how they planned to make improvements in recording baseline information and strengthening monitoring systems to ensure risks were identified and managed. Whilst we had identified some shortfalls in managing risk, health professionals told us staff recognised deterioration quickly, and staff escalated concerns. One professional told us, “I believe that they have a good relationship with the local surgery and feel that they can call for support when needed which is very reassuring.”

People were supported in safe environments that were regularly assessed. Environmental risks within individual flats were reviewed, and adaptations such as profiling beds, commodes, shower chairs and door openers were secured through joint working with housing and specialists. Fire safety arrangements were tailored to the extra‑care setting, with bespoke training developed for the scheme. While the provider is not responsible for the building itself, they acted promptly when risks were identified and worked with the housing partner to arrange necessary adjustments.

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. Staff were recruited safely in accordance with regulatory requirements, with appropriate checks completed before employment commenced. Staffing levels were appropriate, including waking night cover, and people told us staff responded quickly when needed. Staff were consistently positive and described feeling well supported by managers and colleagues, with access to supervision, observations and a wide range of training, including Parkinson’s, dementia, moving and handling and safeguarding. One staff member told us, “I enjoy the online training and it supports me in my role. There is support from my manager if I need more training on specific areas - this was discussed recently at my appraisal.” New staff told us they received a well‑structured and comprehensive induction which ensured they were fully supported before working independently. This included a minimum period of shadowing experienced colleagues across a range of shifts and care tasks, giving them meaningful opportunities to observe best practice.

Infection prevention and control arrangements were effective. Staff had access to a broad Infection Prevention and Control (IPC) training programme, and policies aligned with national guidance. Audits were completed, and no concerns were raised about hygiene or safe waste management. Staff understood PPE requirements and professional feedback described the environment as clean and well maintained.

The provider did not make sure that staff supported people with medicines and treatments safely. Medicines processes required significant improvement. Some people did not always receive time‑critical medicines in accordance with the prescribers’ instructions. The provider and staff had not effectively identified the repeated timing errors which had occurred over a significant period. National institute for Clinical Excellence (NICE) guidance sets out the requirement for time‑specific medicines to be administered exactly as prescribed to maintain their effectiveness to prevent avoidable deterioration in a person’s health. For people with Parkinson’s disease, late medication administration can lead to immobility, increased pain, tremors, swallowing difficulties and a greater risk of falls or choking. Although we did not identify any direct incidents of harm, staff described an increase in “slips” for one person, which highlighted the potential risks associated with inconsistent or delayed medicine support. These patterns suggest that even when harm had not yet occurred, gaps in timely or accurate medicines administration could contribute to avoidable instability and increased risk of falls or deterioration. The registered manager told us they had sought advice from health professionals following this issue being identified and was working on improvements to medicine administration systems.
There were gaps in risk assessments for alcohol interactions with people’s medicines and decision‑specific capacity assessments were absent where dementia potentially affected people’s decision‑making. Inconsistent documentation across paper and electronic systems meant the provider could not demonstrate safe oversight of medicines.
Whilst there were significant shortfalls in medicine processes, staff and managers told us how their competence was routinely observed in practice, with managers completing observations and medication competency checks to confirm safe techniques.