Osborne Court

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 leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant that 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 provider was in breach of legal regulation in relation to the governance of 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.

There were 5 core values across the workforce: Courageous, Ambitious, Responsive, Empowering and Supportive. The trust’s vision was “Working Together for Outstanding Care.” The provider’s values were upheld by the management team.

The provider fostered a positive culture that ensured each individual person was at the centre of decisions made within the service. One staff member told us, “I have learnt so much here. I don’t think you can get a better place as a learning disability nurse.”

Leaders did not always have the skills, knowledge, and experience to lead effectively. We identified breaches of legal regulations and concerns in areas such as safe care, Mental Capacity Assessments and consent and governance. Leaders had not independently identified some of our concerns as they were not acted on prior to our assessment, for example, there was a lack of oversight of health and safety concerns within the care environment.

Staff were positive about management at the service and could name senior leaders within the trust. One staff member told us, “Leaders have been much more visible recently… they are very approachable.” Another commented, “[Manager] is very open door, so is [manager] so we can go to them at any time. I always feel in safe hands with them.”

Management was knowledgeable about issues and priorities for the service. They understood their responsibilities and were supported by the provider to deliver good and effective care.

Staff felt they could speak up and their voice would be heard. Staff felt able to raise concerns with management and felt they would be listened to. One staff member told us, “I would also raise concerns, [name of manager] is extremely confidential.”

The trust had a Freedom to Speak Up guardian and an established process for staff to confidentially raise concerns. All staff we spoke with about this topic told us that they were aware of how to use the Freedom to Speak Up process or knew where to find further information on this process.There was a whistleblowing policy in place to support speaking up.

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.

The trust had a range of staff networks, including ENRICH (Equality Network for Race Inclusion and Cultural Heritage,) Staff Disability Network and the Carers Staff network.

Staff could apply to work flexibly and flexible working arrangements were in place to account for personal circumstances such as health issues.

The trust has an Equality, Diversity, Inclusion and Equity Strategy (EDIE) called “Harmony in Diversity: Creating a Community for All.” The strategy sets out 6 objectives with measures of success and timeframes for completion, including increasing the diversity of their workforce.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider produced a monthly integrated governance report that measured progress against the Care Quality Commission’s key questions and fundamental standards of care. The monthly reported had metrics to measure progress against these standards and any measures of mitigation in place. For example, the report looked at staffing levels at the service and documented the impact on people’s care and support.

Although some areas of good practice were observed, systems did not always effectively assess, monitor or improve the quality and safety of the service or mitigate risk. Provider audits had not identified the concerns we found during our assessment, such as health and safety concerns in the environment and poor record keeping.

We identified several concerns with the safety of the environment at the time of our assessment. We reviewed health and safety audits which identified risks within the environment; however, we found that these were not always completed in a timely manner. The trust told us that health and safety audits should be completed annually, however we only saw audits from October 2023 and September 2024 (relating to the children’s service only.) We did not see evidence that annual health and safety audits had been completed for the adult’s service.

Prior to our assessment, there was no schedule for auditing care plans and risk assessments. Although care plans were routinely annually reviewed with people and relatives, systems and processes in place were not robust in identifying gaps and inconsistencies within care records.

The provider acted in response to the concerns we identified to reduce ongoing risks to people; however, improvements were required to ensure systems and polices were fully understood and embedded at the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and the management team were open and transparent, and they collaborated with relevant external stakeholders and agencies. The service worked in partnership with health and social care professionals and management told us they had built a positive working relationship. One staff member told us, “We have a good relationship, and they are pretty good, we often have Teams meetings.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged ways of delivering equality in experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

The trust had quality improvement training available for all staff (Quality, Service Improvement and Redesign (QSIR) programmes) to support quality improvements at all levels. Staff could apply for introductory, intermediate or advanced level training and could further information of quality improvement initiatives on the intranet. The leadership and management training also had a module on quality improvement.