“PEOPLE’S rights and safety were not always fully protected” at a Worcestershire NHS care service for vulnerable adults and children, a report has found.
A Care Quality Commission inspection found that Osborne Court in Malvern breached regulations relating to Need for Consent, Safe Care and Treatment, and Good Governance.
The watchdog rated the service, which cares for people with learning disabilities on Osborne Road, as requiring improvement in a report published this summer.
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Inspectors found care was person-centred, but said the rights and safety of people using the service were not always fully protected.
It also found leaders lacked sufficient oversight to ensure people were empowered and consistently received safe, high-quality care.
For example, the report explained: “People with medical and health conditions were not always supported safely to protect them from the risk of avoidable harm.
“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.
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“Although there were areas for improvement, good practice was also observed in care records.”
The inspection also found an unlocked knife drawer, loose plaster above the bath, and a nail hanging out of a playhouse.
However, the report also highlighted the positive relationships between staff and those using the service, noting that staff knew people well and provided supportive, personalised care.
People using the service said they trusted staff, with some describing Osborne Court as being like a second home.
Worcestershire County Council commissioned adult replacement care services (also known as respite care or short breaks), which Herefordshire and Worcestershire Health and Care NHS Trust delivered until June 2026.
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The report was published in July.
The NHS Trust still manages the children’s services at Osborne Court but said it still considers feedback from both adult and children’s services.
A new service provider has taken over the management of adult services at the site.
Herefordshire and Worcestershire Health and Care NHS Trust on published report
A spokesperson for Herefordshire and Worcestershire Health and Care NHS Trust said: “We welcome the feedback from the CQC and have taken action to strengthen our practices and address the areas of concern identified.
“We remain committed to providing safe, effective and high-quality care through the children’s short break services that continue to operate from the site and are proud of the person-centred care delivered by our teams.
“We continue to use feedback and learning to review and strengthen our processes, supporting ongoing improvement and high standards of care for patients, service users and their families.”