Osbern Manor Care Home

On this page

• 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 require 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 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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.
Staff described the culture of the home as friendly, supportive and a place where they enjoyed working. Hospitality and care staff told us they felt part of a team and valued being able to contribute to people’s wellbeing. One staff member said they were “I’m happy here very well supported,” reflecting a positive and approachable culture across the home. Managers were visible and staff said they were easy to speak to, which helped maintain a shared understanding of expectations and supported good teamwork. The provider’s own values, which focus on person‑centred and compassionate care, were reflected in the way staff spoke about their work and the pride they took in supporting people.
Staff meetings showed that leaders communicated clearly about standards, but also identified areas where the culture needed strengthening, such as attendance at meetings, punctuality and maintaining professional standards. Managers addressed these issues directly, offering support and giving staff opportunities to ask questions. This showed that leaders were willing to listen and take action to uphold a positive and consistent culture within the home.
 

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.
Staff told us leaders were approachable, supportive and regularly visible in the home. Managers were described as easy to speak to, and staff said they felt listened to and well supported in their roles. One unit manager spoke positively about the development opportunities available, which helped build skills and confidence across the leadership team. Leaders communicated openly about expectations, and staff meetings showed they were willing to address issues such as punctuality or professional conduct directly while offering support. The provider’s website describes a leadership approach based on compassion, partnership with families and a commitment to high quality, person centred care, and this was reflected in how staff spoke about their managers.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
Staff told us they felt confident raising concerns and believed managers would listen and act appropriately. They described the home as open and supportive, with strong team relationships that helped them share issues early. Staff said they would speak to the registered manager and/or deputy if they had a worry. Telling us, “The manager and deputy are very approachable, I would have no hesitation raising anything.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.
Staff described positive working relationships and said they felt respected and treated fairly. Staff from different roles and backgrounds expressed positive views about the working environment and said colleagues worked well together. The provider’s internal development pathways offered training and progression opportunities, supporting equality of opportunity. Staff told us the workplace culture was inclusive, and no concerns were raised regarding discrimination.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.
Governance systems failed to identify or address significant concerns across multiple areas including MCA compliance, care records, incident management, and medicines documentation. These failings were widespread, repeated across several months, and represented a significant breakdown in governance oversight
The service carried out a range of audits and checks, but these did not identify or address many of the concerns we found during the inspection. The audits we reviewed focused mainly on whether documents were present rather than whether they were accurate, up to date or reflected people’s needs. This meant important issues in care plans, mental capacity documentation and incident management were not picked up. Head office audits of care plans and medicines also did not lead to lasting improvements. The same problems appeared across several months, and actions were often reassigned or left without clear evidence of completion, so errors continued. Staff meeting records showed that managers were aware of recurring issues—such as poor incident recording and gaps in documentation—but these had not been resolved. Overall, the governance systems in place did not give the registered manager the support or oversight needed to ensure safe, consistent and well monitored care.

The provider clearly understood and carried out their duty to collaborate and worked in partnership, and services worked seamlessly for people. They always shared information and learning with partners and collaborated for improvement.
Osbern Manor Care Home had exceptionally strong links with its local community, and people benefited from a wide range of meaningful opportunities to stay involved in community life. The home worked closely with local groups, organisations and community initiatives, allowing people to take part in creative projects, environmental activities and social events both inside and outside the home. These partnerships helped people feel connected, supported wellbeing and created a sense of belonging. Staff and people also contributed to wider community causes through fundraising, creative contributions and awareness events, which helped maintain purposeful links beyond the home. Leaders described positive collaboration across other homes in the provider group as well, which supported shared learning and staff development. These strong and varied community relationships showed a clear and exceptional commitment to helping people maintain social connections, feel valued and remain active members of the wider community.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.
The service responded positively to the feedback we gave during our visit and managers were open, reflective and willing to improve. However, many of the issues we identified had not been recognised or addressed through the service’s own learning processes, which meant improvements were happening only after external prompting rather than through proactive review.
Leaders told us they were acting on our findings, but this reactive approach showed that learning was not yet embedded in everyday practice. The registered manager told us they had begun taking steps to improve including updating risk assessments and care plans more thoroughly, improving medication checks, reviewing “as needed” medicines and strengthening how decisions about mental capacity are recorded. These changes had only recently started at the time of our inspection, and we will review their impact at our next visit.