Osbern Manor Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation consent to care and treatment.
 

This service scored 58 (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 make sure people’s care and treatment were effective because they did not always check people’s needs assessments had been reviewed, updated and reflected care provided.

Staff did not always assess or review people’s needs in a way that gave them clear and up‑to‑date information. Some care plans contained old or conflicting details, including information written before a person moved in that had not been updated after changes in their health, mobility or skin condition.

Although care plans were reviewed each month, these reviews often recorded “no changes” even when other records showed important developments, such as new pressure‑area risks, repeated falls or reduced mobility.In some cases, important updates were added at the end of the main care plan, which may present a risk of staff who were less familiar with the person not always recognising the updated information needed support safe and person‑centred care.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

We found gaps in how the service applied recognised clinical tools such as the Waterlow pressure‑area assessment and the Malnutrition Universal Screening Tool (MUST) nutritional screening tool. These tools are important because they guide staff on what actions are needed to reduce risks such as pressure ulcers or malnutrition. In one case, a person had a very high Waterlow score, which indicates a significantly increased risk of developing pressure damage and usually requires clear evidence‑based actions such as regular repositioning, enhanced skin checks and appropriate pressure‑relieving equipment. Although the person did not have a pressure ulcer at the time of our visit, the plan described only “moderate” need and did not reflect the level of clinical risk identified. Similarly, we could not see whether people’s nutritional risks were being assessed using the MUST framework or how weight changes, appetite or fluid intake were being reviewed. While no harm had occurred, the absence of this structured monitoring meant the service could not demonstrate that people were receiving the full level of evidence‑based prevention expected for those at higher risk.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff worked well together across the home, and people told us the atmosphere was friendly and supportive. Each floor had a consistent team of nurses, senior carers, care staff and hospitality staff, which helped people know who to go to if they needed help. Staff explained how they shared information with each other during handovers and throughout the day, which helped keep care coordinated. Unit managers told us they felt well supported and had completed extra in‑house training so they could work confidently alongside nurses. People also noticed the positive teamwork, with one person telling us staff were “always on the ball,” and we saw staff speaking kindly to people and to each other during the visit.

Staff also worked effectively with external services when people’s health needs changed, and they shared information with hospitals when people needed to transfer for treatment. This helped ensure people received the right care at the right time.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support.

People were supported to access healthcare when they needed it, and staff worked well with external professionals to help people stay as healthy as possible. People told us staff arranged appointments for them, with one person saying, “They organise everything for me.” Records showed that GPs reviewed changes in people’s health, including mood and alcohol intake, and discussed decisions with people and their families. District nurses were also involved when needed, for example when there were concerns about catheter‑related infections or after a fall. One relative told us that a paramedic visited regularly, and that the person they cared for also saw a chiropodist, dentist and optician when required.

The home also offered opportunities that supported people’s physical and emotional wellbeing. People were encouraged to take part in local community projects, such as tree‑planting events and beach clean‑ups, which gave them gentle exercise, fresh air and social contact. These activities, alongside the support from health professionals, helped people maintain a healthier and more active lifestyle.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and
consistent, or that they met both clinical expectations and the expectations of people themselves. We saw examples where people experienced falls or changes in their mobility but these were not used to build a clear picture of whether someone’s condition was stabilising, worsening or requiring a different approach. People with health conditions that typically require regular monitoring, such as catheter related risks, hydration concerns or pressure area vulnerability, did not always have ongoing checks carried out to monitor whether these risks were becoming more concerning. We discussed this with the registered manager, and they told us they would introduce additional checks for the people affected. However, these steps were reactive and had not formed part of the service’s usual approach to monitoring outcomes.
Staff were attentive and caring, and some outcome focused systems existed, but they were not used consistently enough to provide a reliable understanding of people’s progress. As a result, the service could not always demonstrate people were supported to achieve the best possible health and wellbeing outcomes.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.
They did not always follow the legal requirements of the Mental Capacity Act 2005 (MCA) when people were unable to make specific decisions, as capacity assessments were not decision focused, best interest decisions were missing and some consent forms had been signed by family members without the legal authority to do so. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the MCA. We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that DoLS had been applied for but there was a lack of supporting evidence to ensure these were appropriate meaning the service could not show that people’s rights were fully protected. We also found that a condition requiring regular reviews for someone with a Deprivation of Liberty Safeguards authorisation had not been completed.
However, people told us staff always asked for their consent and explained what they were doing, and staff showed a good understanding of seeking consent in everyday care. Managers were responsive to feedback and had begun improving how capacity and consent information is recorded and reviewed.