Osmund Court (Care Outlook)

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
This is the first assessment for this newly registered service. This key question has been rated requires improvement.
This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.
 

This service scored 57 (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 did not always have a clear shared direction or consistently embedded culture. The service benefited from a cohesive and committed local team who shared a strong sense of purpose and worked collaboratively to support people well. Staff consistently described the culture as supportive and inclusive. While there was strong evidence of a kind, compassionate and person‑centred ethos described by people, relatives and staff, this was not consistently supported by structured systems that ensured the vision was reliably delivered. Key processes to support and reinforce shared culture such as pre‑assessment, risk management, capacity and consent, and consistent documentation were not reliably applied across the service. This inconsistency meant leaders could not always assure themselves the culture was applied in practice for every person. For example, significant gaps in risk assessments, incomplete use of clinical tools, and fragmented record‑keeping made it difficult to demonstrate safe, consistent practice aligned with the intended vision.

Leaders were compassionate, visible and trusted, but did not always have the knowledge or supporting systems needed to ensure safe and effective governance. People, relatives, staff and professionals consistently praised the registered manager as passionate, approachable and committed to person‑centred care. Comments from professionals included, “[Registered manager] is very passionate about supporting people and promoting independence wherever they can possibly can”, And “[Registered] Manager is approachable and responsive, they strive to have a staff group happy in their jobs, which in turn impacts on the [people].” Staff felt valued and supported and described open relationships with managers. Leaders had introduced new tools and updated policies as part of an improvement project, showing commitment to development.
However, leaders did not always ensure systems were effective. Governance processes were not always in place or were fragmented which resulted in shortfalls in the services ability to monitor the quality of the service or demonstrate continuous improvement. As a result, despite strong relational leadership, there were gaps in risk oversight, audits and assurance which limited leaders’ effectiveness and prevented the consistent delivery of safe, well‑governed care
 

The provider had a culture that supported people to speak up and ensured staff felt safe to raise concerns. Staff consistently reported that they could openly share ideas, raise issues and discuss incidents in regular supervision, spot checks and meetings. They described the culture as open where concerns were listened to and followed up. Staff had confidence in the registered manager and senior staff, who were approachable and promoted openness. Staff said they could contribute suggestions for activities, improvements and day‑to‑day practice, demonstrating psychological safety and inclusive communication.

The provider promoted an inclusive and supportive working environment, creating conditions in which staff felt respected and valued. Staff described strong team relationships and a culture of inclusion highlighting an environment characterised by mutual respect, compassion and emotional support. Training was comprehensive and included equality and diversity, dementia, safeguarding and learning disability training, reflecting a commitment to inclusive practice and meeting diverse needs. Staff reported that managers were approachable and supportive, which contributed to wellbeing and retention.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes. Governance systems did not consistently ensure safe, effective and sustainable care. Although leaders had updated policies and introduced new tools and logs, these were not yet fully embedded or effective. Audits did not reliably identify issues in key areas such as initial assessment, care planning, medication management, incident analysis and application of the Mental Capacity Act. There was a lack of effective senior‑level oversight of governance and safety processes, which meant the provider could not demonstrate systems were sustainable or operating as intended. Although the registered manager worked hard to maintain day‑to‑day oversight, the provider was unable to show organisational monitoring of key safety and quality systems, for example, incident management. The provider was unable to evidence their incident management process, including how senior leaders checked or assured themselves of the registered manager’s analysis of incidents. The lack of structured senior‑leader monitoring meant important safety issues could go undetected, and the service could not be assured incidents were reviewed, escalated, or learned from in a consistent and robust way.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The provider worked effectively with system partners and professionals to support people’s outcomes. Professionals described “excellent” partnership working and highlighted strong collaboration with occupational therapists, physiotherapists, GPs, community nurses and specialist roles such as Parkinson’s nurses. The service collaborated well with housing and the local authority, conducting joint assessments, resident meetings and coordinated responses to shared challenges. This helped ensure consistency between care, housing and social support.
People had access to community activities, including church, charity groups, trips and social events, supporting community connections and wellbeing.
 

The provider demonstrated commitment to improvement however learning was not consistently embedded or supported by reliable systems. Leaders had introduced updated policies and new governance tools, including improved templates and training enhancements such as bespoke fire courses. However, learning from incidents and audits was not sufficiently robust. Incident and safeguarding oversight was still developing, and there were gaps in identifying themes such as medicine and potential links to falls. Audits did not consistently detect repeated medicine timing errors in a timely manner or issues with assessment and care planning. Although there was a positive culture of reflection among staff and managers, the absence of consistent, structured processes limited the provider’s ability to fully embed learning and drive continuous improvement.