OSJCT Coombe End Court

The provider now had effective systems to ensure the security of the building at night, which records demonstrated staff followed consistently. Doors to cupboards used for storage of chemicals were now kept locked when not in use.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. People had enough to eat and drink to stay healthy. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff now kept contemporaneous records of the support they provided to support people to manage risks, including ensuring people were regularly re-positioned and recording well-being checks. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff took decisions in people’s best interests where they did not have capacity. The service was now clean and well maintained throughout.

People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated people as individuals and supported their preferences. People had choice in their care and were encouraged to maintain relationships with family and friends. Staff responded to people in a timely way. The provider supported staff wellbeing.

People were involved in decisions about their care. Staff provided information people could understand. People knew how to give feedback and were confident the provider took it seriously and acted on it. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

The provider now had effective systems to assess how the service was operating and plan improvements where needed. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment.

The provider had systems in place to share learning from incidents in other services. However, we observed learning from other services had not always been implemented consistently. For example, learning relating to the safe storage of denture cleaning tablets had not been implemented in the service’s own internal shop and learning regarding the position of wheelchair footplates was not consistently followed. The manager took immediate action to address these issues during the inspection.

The provider had not always made sure that people received the medicines they were prescribed. The service had experienced a high level of medicines errors in April 2025, including incidents in which people were not supported to take their prescribed medicines. The provider had worked with external professionals to address the issues. This had resulted in a reduction in errors for during May 2025, all of which related to recording rather than errors in the medicines people received. The provider had action plans in place to reduce errors further and ensure improvements were sustained. Medicines administration records we checked for the week of the site visit had all been fully completed, with people supported to take the medicines they were prescribed.