Osbern Manor Care Home

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 good. This meant people were safe and protected from avoidable harm.

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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.
The service has systems to record incidents and accidents, and we saw a large number of entries for falls, skin tears, unexplained bruising, pressure ulcers, distressed behaviour, medical episodes and equipment related incidents. These were recorded consistently, with supporting wound charts, body maps and updates to care plans where needed. Staff usually responded quickly, carrying out post fall checks, contacting GPs, paramedics or tissue viability nurses, and informing families. This showed that individual incidents were recognised and dealt with at the time.
However, the provider had not completed any updated analysis of incidents and accidents since April 2025. The registered manager told us this work has been paused centrally while the electronic systems are being fully integrated.
While this was on hold, the management team continued to review incidents through monthly Clinical Governance Reports. The provider’s Director of Care and Governance reviewed all reports from each home, and any organisation wide learning is shared across services.
The registered manager explained that, over the past three months, several improvements have been made as a result of earlier analysis. These included introducing sensor mats for people who are cared for in bed, reviewing staffing levels more regularly to ensure enough support at higher risk times, and changing the shift start time from 8am to 7am after identifying that more falls were happening in the early morning.
 

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.
People were assessed before moving into the service to make sure their needs could be met safely. Clear systems were in place to support coordinated care across the different floors. Staffing was organised so each floor had a defined structure, with nurses, senior carers and care staff allocated consistently. This helped maintain continuity and meant people and visitors knew who to approach for support at different times.
Staff used electronic systems to manage care plans and handovers, and these could be shared with hospitals when needed to support safe transfers. Staff we spoke with, including unit managers, were confident in their roles and clear about how care tasks and clinical support should be coordinated. This supported safe day to day working and helped ensure that people experienced smooth and well managed care pathways.
 

The provider worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives and 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 told us they felt safe, and 1 relative told us they “don’t have to worry anymore.” Due to the care their loved one was receiving.
People were supported by staff who understood their day to day needs, and we did not find evidence of abuse, neglect or unsafe treatment in the records we reviewed.
Staff we spoke with understood safeguarding principles and said they felt confident raising concerns with managers. People told us, “Yes, [I feel] very safe having staff around all the time to help. Couldn’t have picked a nicer place.” and “I feel very safe and happy – there is always someone around.”
Staff kept relatives informed when incidents had occurred which demonstrated openness and transparency in communication. While the review of care plans and incident forms showed some gaps in documentation quality, such as missing injury checks, incomplete forms or delays in recognising deterioration, there was no evidence that staff failed to act to protect people from harm, and the issues identified relate to record keeping rather than unsafe practice.
 

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
The service did not always effectively manage risks to people, because individual risk assessments did not clearly set out what staff should do to keep people safe. In several records we reviewed, important risks were not matched with clear, up to date instructions for staff to follow. This meant care plans did not always reflect what had happened recently or what actions staff needed to take next. Although we did not find evidence that people had been harmed, the lack of clear and current risk information increases the chance that staff may respond inconsistently, particularly those who are new or unfamiliar with the person.
We fed this back to the registered manager during our visit. They accepted this and committed to reviewing and updating residents’ risk information. We have seen evidence that this work has begun and will check progress at our next inspection.
 

The provider was fully aware of all potential risks in the care environment and controlled them well. They made sure equipment, facilities and technology supported the delivery of safe care.
The home provided an excellent and well maintained environment that strongly supported safe care. During our visit we found the building to be extremely well presented, with bedrooms, bathrooms and communal areas kept to a very high standard. People’s rooms were personalised and homely, helping individuals feel comfortable and at ease, and the overall atmosphere throughout the home was quiet, calm and welcoming. A relative told us, “It’s quiet, calm, safe – we don’t have to worry anymore,” reflecting how strongly the environment contributed to people feeling protected and well supported. The laundry, housekeeping and hospitality teams played a key role in maintaining this high standard, and we saw them carrying out their work with care, professionalism and a friendly approach.
Equipment across the home was modern, accessible and ready for use, including hoists, bathing facilities and mobility supports. During our walkaround we observed no hazards, defects or unsafe equipment, and bathrooms and storage areas were clean, organised and free from inappropriate items. Staff were clearly attentive to maintaining a safe physical environment, and people confirmed that the home was cleaned daily and consistently well presented.

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 gave us generally positive feedback about staffing. One person told us, “Yes, I think so, although if someone goes off sick they can be short,” while another said, “Oh yes, they come quickly,” when using their call bell. A third person told us, “They seem to know what they are doing,” which reflected confidence in staff skills.
Staffing allocations were clear, with nurses, senior carers, care staff and hospitality teams deployed consistently across floors. This helped ensure people knew who was available to support them at different times. Staff told us they had good access to training, including e learning, face to face sessions, language support and the provider’s internal advanced practitioner programme, which supported professional development.
Training records showed that the service expected staff to have the right skills and knowledge to keep people safe. Most staff had completed between ninety and one hundred per cent of their required training in subjects such as safeguarding, basic life support, infection control, moving and handling and emergency procedures. Staff also had opportunities to learn about dementia care, communication, equality and diversity and activity support so they could meet people’s individual needs.
Probation records showed that new staff were monitored closely and given feedback to help them develop confidence and competence. Staff were also recruited safely. The personnel files we checked contained the correct checks and documents to make sure only suitable staff were employed.

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.

The service had effective infection prevention and control practices in place. Throughout our visit, the environment was exceptionally clean, and we saw staff following safe hygiene routines as part of their everyday work. Bathrooms, bedrooms and communal areas were hygienic, tidy and well maintained, and we did not see any signs of lapses in cleanliness. People told us the home was always clean, with one person saying it was “spotless, eleven out of ten,” and another telling us, “They clean every day.” Staff understood their responsibilities for maintaining good hygiene, and we saw that personal protective equipment was used correctly. Equipment and facilities were clean, safe and ready to use.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Systems that supported safe medicines practice were not always robust. Some “as needed” (PRN) medicines, including those used to support constipation, did not include the clear instructions staff needed to make safe and consistent decisions. For example, protocols did not explain when staff should consider administering these medicines, or what staff should monitor afterwards to check whether they had been effective. Without this information, staff may rely on individual judgement rather than following a consistent plan, which increases the risk of medicines being given incorrectly.

There was no indication that people had been harmed, and staff acted promptly when issues were identified. However, the gaps in PRN guidance and record keeping reduced overall confidence that medicines were always managed safely and in line with best practice. The registered manager agreed to strengthen PRN protocols and ensure record keeping supports safe and reliable medicines administration.

People told us they received their medicines safely and on time, and we saw that staff gave important medicines, such as those for Parkinson’s disease, at the right times. People said they trusted staff with their medication, telling us, “The staff come around and give me my medication – I trust them,” and “I always get my medication on time; they look after me from my head to my toes.”