Osborne Court

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.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant people were not always safe and protected from avoidable harm.

The provider was in breach of legal regulation in relation to detecting health and safety risks within the environment and the management of choking risks.

This service scored 59 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff told us they felt confident in raising concerns with the provider. One staff member commented, “Leaders are very approachable, and I can raise concerns if needed.”

Lessons were learnt to continually identify and embed good practice and any incidents about people’s safety were discussed with staff. A staff member commented, “Learning would be fed back in team meetings or team debriefing sessions… we really focus on lessons learnt here.”

People had access to professionals, family and friends outside of the service they could raise concerns with about their safety. Relatives told us they felt confident that the service would act. One relative commented, “I have raised a few minor things, and they address it as soon as it happens… it hasn’t happened since.”

The provider had identified learning from an incident relating to lack of escalation when identifying unexplained injuries. The service had introduced body maps to be completed prior to the person’s stay as part of the handover protocol, to keep track of injuries, rashes, pain or other areas of concern to meet people’s health and wellbeing needs. We saw that learning had been shared with staff in team meetings and saw evidence that learning had been embedded into practice.

Information was collected before people commenced care at the service and care records were developed using this information. The service used as assessment pack to obtain the relevant information that they needed. Staff told us, “We invite them over for a cup of tea and slowly build this information up.” The service formulated care plans and risk assessments from this initial meeting and updated these records moving forward.

Relatives spoke about the collaboration and support offered when people moved between services. “[Person] went to children’s Osborne Court then across to adults. The transition was great, staff took [person] across to adults for teatimes and bath time to slowly meet the staff.”

Some people using the service would visit day centres external to the service. The service used communication books with the day centre to hand over relevant information.

People using the service were observed to be well treated and cared for, and we received positive feedback from relatives on the safety of people. One relative told us, “If I thought it was unsafe or [person] was being mistreated, then they wouldn’t be going, but it is a home away from home.”

Safeguarding details were displayed on the staff notice board for easy access, and staff could explain how they escalated concerns.

Staff had received training about safeguarding adults and children from abuse. In the children’s service, non-qualified staff completed Safeguarding Children Level 2 and qualified completed Safeguarding Children Level 3. At the time of our assessment, all staff had completed the appropriate training.

Staff knew how and when to report concerns. Staff could give examples when they had identified potential abuse and neglect and had reported this to the local authority.

When people lacked capacity to consent to being in the service, a Deprivation of Liberty Safeguards (DoLS) authorisation had been applied for. These are legal procedures designed to protect people who may lack the capacity to make informed decisions about their care and treatment in hospital. Authorisations were not always in place at the time of our inspection; however, applications had been made and the provider had received confirmation that the local authority was dealing with their application. The provider has received correspondence from the local authority in relation to this and this was documented in care records.

The provider did not always work well with people to understand and manage risks. Risks to people’s health and safety were not always robustly assessed, monitored and mitigated.

Risk assessments and care plans were in place, specifically addressing risks people could experience. However, information in people’s records was not always accurate or reflective of their needs. For example, we reviewed a person’s “behaviour care plan” which gave guidance for staff to follow to keep people safe when the person was expressing distress or agitation. It was documented in the care plan that staff should “redirect” and “distract” however information was limited so it was not clear exactly what this meant. This was raised with staff, and it was evident that they knew the person well and would know how to support them, however, the information was not detailed for newer or temporary members of staff.

People with medical and health conditions were not always supported safely to protect them from the risk of avoidable harm. For example, although one person had been identified as at risk of choking, timely action was not taken to address this and the appropriate referral had not been made, therefore the person was placed at an increased risk of aspiration. This was raised with the service, and the management team took immediate action, including a review of the eating and drinking care plan and a referral to the SALT (Speech and Language Therapy) team.

Although there were areas for improvement, good practice was also observed in care records. For example, we reviewed a person’s communication care plan in the children’s service and this robustly guided staff in managing their specific communication needs, including a communication book. The communication book was holistic, and person centred.

People and relatives were involved in care planning. Relatives told us they were informed of any changes in people’s presentation, and those changes were reflected in care records. One relative commented, “We go through them every 12 months.”

The provider did not detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We observed several areas of concern in the environment across both the adults and children’s services. For example, in the adult’s service, we found an unlocked knife drawer which was accessible to people using the service and found loose plaster above the bath in a communal bathroom. In the children’s service, the kitchen and children’s playhouse were in need of modernisation and refurbishment. We saw that there was a nail hanging out of the playhouse which posed a risk to the safety of children using a service. This was raised with the service and staff took immediate action to make the playhouse safe. The service was waiting for a new kitchen and had applied for this prior to our assessment.

Although the service had identified some of the concerns we identified onsite, systems and processes were not always effective at identifying potential risks in the care environment. For example, health and safety audits were not always completed in a timely manner to identify and manage potential safety risks within the environment.

Staff ensured people had Personal Emergency Evacuation Plans (PEEPs) in place so that staff and emergency services could ensure people were safely evacuated. The PEEPs were in people’s individual records, both physically and electronically. Information in the PEEPs was mostly detailed, however the “place of safety” was not always clearly documented.

The provider made sure there were enough qualified, skilled and experience staff who received effective support, supervision and development. They worked well together to provide safe care that met people’s individual needs.

Staffing levels were planned in accordance with the number of people accessing the service and their assessed care and support needs. We observed a good staff presence during our visit and people did not have to wait for assistance. Although we received positive feedback on the staff, relatives felt that staffing levels were not always sufficient to meet peoples needs. One relative commented, “staff are amazing but frustrated because of staff shortages” with another adding, “I will get calls before, sometimes on the day, cancelling.”

The service used NHS Professionals (NHSP) bank staff, who were fully inducted and worked regularly within the service, to help cover staffing shortfalls, for example during periods of staff illness. The provider advised that agency staff were not used. Staff told us that it could sometimes be difficult to fill staffing gaps, which at times resulted in cancellations of people's respite. One staff member commented, “We would never open with unsafe staffing so we would rather close, we would all put in an extra shift here and there but it is not always possible.”

The provider’s procedures for staff recruitment ensured that they were recruited safely with the appropriate pre-recruitment checks. This included references and a check with the Disclosure and Barring Service (DBS) before staff worked with people. DBS checks provide information about details of convictions and cautions held on the Police National Computer. This information helped the provider make safe recruitment decisions.

All staff received a period of induction which gave them the skills and knowledge to meet people’s needs. Staff worked alongside more experienced staff during their induction to enable them to get to know the people using the service.

Temporary staff received an induction to the service, including allowing time to familiarise themselves with people’s individual needs and competency checks by more experienced staff. One staff member commented, “Everyone that works here already knows the service quite well, but they always do shadow shifts when they start.”

Staff had access to a range of mandatory training to provide them with the skills and knowledge required to meet people’s care and support needs. This included health and safety, infection control, equality and diversity, moving and handling, and safeguarding adults and children. Compliance rates for the mandatory training of all staff were 98% in August 2025.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed several Infection, Prevention and Control (IPC) concerns in the adult’s service. The environment was visibly unclean, and we observed stained furniture in the communal lounge area and throughout the environment. We found that fridge temperatures were not always recorded, or temperatures were recorded as too high. Food was not always labelled in the fridge, so it was not always clear when food had been opened. We saw a visibly unclean tray in the communal lounge area of the adult’s service and food remnants in a basket of toys in one person’s room. A basket of laundry was also left on the table in the communal lounge area. This was raised with the service and action was taken immediately. There were visible improvements made to the care environment when we returned the following day. In the children’s service, we saw rotting blinds in the kitchen, however this has been identified on a previous audit, and the trust was in the process of replacing this.

Staff had access to the appropriate Personal Protective Equipment (PPE) and there was adequate hand washing facilities and access to hand sanitising stations.

Cleaning and Infection, Prevention and Control audits were undertaken to identify and manage risks in the environment. We reviewed the July 2025 cleaning audit for the adult’s service and found that the audit had identified issues we had seen onsite. For example, the audit had identified that the ceiling in the bathroom required filling and painting. However, this had not been amended by the time we visited the service and no information on actions taken or completion date had been documented.

There were systems in place for the safe handling and administration of medicines to help ensure people received their medicines as prescribed. Medicines were stored securely in locked areas with access restricted to authorised staff. However, medicines storage space was not always adequate, and there were few regular clinical pharmacy visits to the location. As a result, oversight of medicines management was limited, reducing opportunities for routine review, additional assurance, and the timely identification of areas for improvement. The provider told us that the lack of pharmacy input had been recognised and was recorded on the Trust Risk Register.