Archived: Osborn Manor

Updated 24 July 2015

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 11 June 2015 and was unannounced. One inspector carried out the inspection.

Before the inspection, we asked the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. They did not return a PIR and told us they had not received this. We took this into account when we made the judgements in this report.

We also reviewed previous inspection reports and looked at our own records such as any notifications of incidents we had received. A notification is information about important events which the service is required to tell us about by law. This information helped us to identify and address potential areas of concern.

During the inspection we spoke with three people, one relative, three staff and the registered manager. It was not always possible to establish people’s views directly due to the nature of their conditions. To help us understand the experience of people who could not talk with us we spent time observing interactions between staff and people who lived in the home. We looked at care records for four people and the medicines records for eight people. We looked at recruitment, training and supervision records for five members of staff. We also looked at a range of records relating to the management of the service such as activities, menus, accidents and complaints, as well as quality audits and policies and procedures.

Updated 24 July 2015

This inspection took place on 11 June 2015 and was unannounced.

Osborn Manor is a service that is registered to provide accommodation for up to 14 older people, some of whom are living with dementia. Accommodation is provided over two floors and there are stair lifts to provide access to people who have mobility problems. On the day of our visit 12 people lived at the home.

Our last inspection at Osborn Manor was carried out on 1 April 2014. At this inspection we found the provider had not complied with regulations which related to care and welfare of people who use services, safeguarding people who use services from abuse, and assessing and monitoring the quality of service provision. We asked the provider to take action to make improvements. The provider sent us an action plan which said they would be compliant by June 2014. We found some improvements had been made but further work was required to ensure they were meeting minimum standards according to the regulations.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People were supported by staff to take their medicines. However, the provider policy for medicines management was not always adhered to and we identified gaps in the recording of medicines. These gaps had not been identified by the registered manager and no action had been taken to address these.

Improvements had been made to protecting people from the risk of abuse. People felt safe and staff knew their roles and responsibilities in protecting people. Where concerns required reporting the provider had ensured this was done. Improvements had also been made to the management of risk and the plans of care for people. Clear risk assessments had been developed and provided guidance for staff. Staff were knowledgeable of people’s needs and the support they required.

People told us the staff were kind and caring. No one had any concerns and said they were happy with the care and support they received. Staff respected people’s privacy and dignity and used their preferred form of address when they spoke to them. Observations showed that staff had a kind and caring attitude. People told us the manager and staff were approachable. Relatives said they could speak with the manager or staff at any time.

Thorough recruitment checks were carried out to check staff were suitable to work with people. Staff were supported to develop their skills through training and supervision. The provider supported staff to obtain recognised qualifications. Staffing levels were maintained at a level to meet people’s needs. The provider was looking to introduce a dependency tool which would support them to monitor the staffing levels in the home. We have made a recommendation about the use of dependency tools when determining staffing levels.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found the provider had suitable arrangements in place to establish, and act in accordance with people’s best interests if they did not have capacity to consent to their care and support. The registered manager understood her responsibility with regard to Deprivation of Liberty Safeguards (DoLS) and they had applied for authorisation under DoLS to ensure people were protected against the risk of being unlawfully deprived of their liberty.

People were satisfied with the food provided and said there was always enough to eat. People were given a choice at meal times and were able to have drinks and snacks throughout the day and night. Improvements were needed where people’s nutrition and hydration needs required monitoring and we have made a recommendation about this. Staff supported people to ensure their healthcare needs were met.

The registered manager operated an open door policy. They had introduced systems to support people, relatives and staff to provide feedback on any aspect of the service. This included regular meetings and annual surveys.

At our last inspection we found the provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people. There were no audits undertaken to monitor the quality of service provided. At this visit we found improvements had been made however, further improvements were needed. Audits undertaken were not effective in identifying concerns and where actions had been identified these had not always been completed. People’s records needed further work to ensure they reflected all their needs.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.