Osborne Court Care Home is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Osborne Court provides accommodation with nursing and personal care for up to 55 people. The home operates on two floors, providing nursing and personal care on the ground floor and personal and nursing care predominantly for people living with dementia on the first floor. At the time of our inspection 38 people were living in the home.

At the last inspection in July 2017 the service was rated Requires Improvement. We found breaches in four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches related to management of medicines, management of risks, people’s care and treatment, staff supervision and quality assurance systems. We issued requirement actions. Following the inspection, the provider sent us an action plan telling us how they would make the required improvements.

We carried out a comprehensive inspection on 7 and 8 August 2018. At this inspection, we found sufficient improvements had been made and the legal requirements had been met. We found further improvements were needed and where improvements had been made, these needed to be consistent and embedded in the service.

Overall, the service has remained as Requires Improvement.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission 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 2008 and associated Regulations about how the service is run.

Sufficient numbers of staff were deployed at the time of our visit. Records showed sufficient numbers were not always deployed. Staff performance was not always effectively monitored.

There were improvements in the management of medicines. Further improvements were needed to make sure shortfalls were promptly identified and addressed.

Staff demonstrated a good understanding of safeguarding and whistle-blowing and knew how to report concerns.

People were helped to exercise support and control over their lives. People were supported to consent to care and make decisions. The principles of the Mental Capacity Act (MCA) 2005 had been followed.

Incidents and accidents were recorded and showed that actions were taken to minimise the risk of reoccurrence.

People’s dietary requirements and preferences were recorded and people were provided with choices at mealtimes.

Staff were kind and caring. People were being treated with dignity and respect and people’s privacy was maintained.

An activity programme was offered and provided entertainment and engagement to people in communal areas and in their rooms.

Systems were in place for monitoring quality and safety. These had not always been effective and did not identify all shortfalls.

We carried out a comprehensive inspection on 27 July 2017. This was the first inspection since the service was registered under a new legal entity, Four Seasons 2000 Limited. The service was previously registered under the legal entity of Laudcare Limited.

The inspection was unannounced. Osborne Court provides nursing and personal care for up to 55 people. At the time of our inspection there were 37 people living in the home.

There was no registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission 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 2008 and associated Regulations about how the service is run. One of the provider’s area resident experience care specialist’s was taking overall management responsibility for the home. They are referred to in this report as the interim manager.

Most people told us they felt safe in the home. However, we found medicines were not always safely managed and risk assessments and risk management plans were not always fully completed. Staff understood their responsibilities with regard to keeping people safe from avoidable harm and abuse.

People‘s healthcare needs were not always met. Staff were not always provided with sufficient information about actions to take when people’s needs changed. Staff were not always provided with sufficient support and supervision.

Staff demonstrated a kind and caring approach and they treated people with dignity and respect. Staff knew people well and were able to tell us about people’s likes, dislikes and preferred routines which were reflected in their care records.

The programme of engagement and activity varied within the home. People living in one area of the home were engaged and occupied. In another area of the home people were not provided with sufficient activity during the day.

There was no registered manager in post. Most people were not aware of the management arrangements in the home. Staff expressed concerns with regard to the lack of consistent leadership and management.

We found four breaches of the regulations at this inspection. You can see what action we told the provider to take at the back of the full version of the report. We also made recommendations for further training to be provided for Deprivation of Liberty Safeguards (DoLS) and diabetes management.