CQC report explained · a nursing home
What the CQC found at Sebright House Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, May 2022
Rated Good overall; inspectors found safe care, but the home's leadership and checks on the environment still needed improvement.
This was an unannounced inspection on 4 May 2022. Inspectors spoke with staff, the manager and 11 relatives. They observed care and reviewed care plans, medicines records, monitoring charts, recruitment files and management records.
The home was rated Good overall. Safe was rated Good. Inspectors found that risks were assessed, medicines were managed safely, staffing levels supported people's needs and staff understood safeguarding responsibilities. The home also followed the required processes for mental capacity and restrictions on people's freedom.
Well-led was rated Requires Improvement, the same as at the previous inspection. Audits did not always identify problems with the building, cleanliness and equipment. Bedrooms were not personalised, and there was no registered manager in post at the time of the inspection.
The overall rating improved from Requires Improvement at the previous inspection to Good. However, the inspection only assessed Safe and Well-led. The other three ratings were carried forward from the previous inspection.
Staffing and attention
Inspectors found enough staff to support people attentively, including people with dementia who could become distressed.
“The numbers of staff allocated to each shift meant staff were attentive to people's needs and responded proactively when needed.” from the report
Risk management
Individual risks, including risks linked to mobility, pressure damage, nutrition and continence, were assessed and reviewed.
“People's care plans and their risk management plans were regularly reviewed to ensure they were up to date.” from the report
Medicines
Medicines were stored, managed and given in line with recognised guidance. Records also supported safe use of medicines given only when needed.
“Medicines were stored, managed and administered in line with good practice guidelines.” from the report
Staff and relative views
Staff said they felt supported and took pride in their work. Relatives generally spoke positively about the care and communication.
“Staff told us they took pride in caring for people and enjoyed working at the home.” from the report
Checks did not find all problems
needs fixingThe home's audits were still missing issues that inspectors found. This included problems with safety, cleanliness and worn equipment.
“At this inspection we found that whilst overall audits were identifying areas for improvement, they were still missing some issues within the environment identified during our inspection.” from the report
Cleanliness and damaged equipment
needs fixingSome bedrooms needed a deep clean. A crash mat and pressure-relieving cushion were damaged and could not be cleaned effectively.
“Also, some bedrooms needed a deep clean. The manager acknowledged our feedback and assured us action would be taken.” from the report
Environmental safety
seriousA broken window sash created a risk of entrapment and injury. Some furniture and safety equipment was worn.
“For example, a broken window sash posed a risk of entrapment and injury.” from the report
Personalising bedrooms
minorBedrooms were not sufficiently personalised, and signage in communal areas did not support people to move around independently.
“People's bedrooms did not demonstrate person centred care.” from the report
Management arrangements
needs fixingThere had been two management changes since the previous inspection, and there was no registered manager in post during this inspection.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01Has the broken window sash been repaired, and how have you checked that there are no similar safety risks?
- 02Which bedrooms and items of equipment needed cleaning or replacing, and has this work now been completed?
- 03How often are environmental audits carried out, and how do you make sure they identify problems that inspectors previously found?
- 04What is the current position on the manager's application to become registered?
- 05How will you help residents personalise their bedrooms and find their way around the communal areas?
This was a focused inspection of Safe and Well-led, including infection prevention and control; the Effective, Caring and Responsive ratings were carried forward from the previous inspection. This explanation was written from the published report of 28 May 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2020
Sebright House Care Home was rated Requires Improvement overall; care was kind and effective, but safety checks and environmental risks still needed attention.
Inspectors made an unannounced visit on 10 March 2020. They spoke with people, relatives, staff and a healthcare professional. They observed care and checked care records, medicines records, staff files and management records.
The home was rated Good for Effective, Caring and Responsive. Inspectors found enough suitably skilled staff, safe medicines practices overall, good support with eating, drinking and healthcare, and kind care that respected people's choices and dignity. Care plans and activities had improved.
Safe and Well-led were both rated Requires Improvement. Inspectors found environmental risks, including unsafe window restrictors, a broken window rope, accessible hot pipes and wardrobes that were not securely fixed. The home had improved since the previous inspection and was no longer in breach of regulations, but further improvements were still needed.
Kind and respectful staff
Relatives described a consistent and caring staff team. Inspectors found that staff were patient, non-discriminatory and respectful of people's dignity.
“Staff genuinely care about people.” from the report
Good staffing and safeguarding
Inspectors found enough staff with the right skills and experience. Staff understood abuse risks and knew how to report concerns.
“There were enough staff with the appropriate skills, knowledge and experience to effectively and safely meet people's needs.” from the report
Improved personalised care
Care plans had improved and better reflected people's needs, preferences and lifestyle choices. Staff used individual interests to provide meaningful activities.
“Improvements had been made to ensure care plans were more reflective of people's individual needs, preferences and lifestyle choices.” from the report
Support with nutrition and health
People's nutrition and hydration needs were assessed and understood. Healthcare professionals were involved when needed, and some people had improved their weight.
“People's nutritional and hydration needs had been identified and assessed and were understood by staff.” from the report
Progress since the previous inspection
The report says the home improved in several areas, including training, care planning, infection control, record keeping and risk management. It was no longer in breach of the two regulations identified at the previous inspection.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Environmental safety risks
seriousSome first-floor window restrictors did not meet safety requirements. A broken sash-window rope, accessible hot pipes and insecure wardrobe fixings also left risks that needed action.
“On the first floor of the home some window restrictors did not meet health and safety requirements which put people at risk if they attempted to climb out of the windows.” from the report
Checks did not find all risks
needs fixingThe home's environmental audits had not identified some of the safety problems. Actions taken to reduce risks were not always completed effectively.
“However, audits of the environment had not identified some of the safety issues we found.” from the report
Some medicines records were incomplete
needs fixingHandwritten changes to medicine records for people in discharge-to-assess beds were not always checked and signed by a second staff member.
“Handwritten amendments to the medicine records maintained for people on 'discharge to assess' beds were not always countersigned by a second member of staff” from the report
End of life preferences
minorThe home had end of life care plans, but the manager recognised that people's spiritual and cultural wishes needed to be explored more fully.
“The registered manager acknowledged they needed to seek people's views about for example, their spiritual or cultural needs during their final days.” from the report
- 01Have all the first-floor window restrictors been replaced or repaired so they meet health and safety requirements?
- 02How have you secured the cupboard containing hot pipes and the wardrobes that were not firmly attached to the wall?
- 03How do your environmental audits now make sure that safety risks are found and fixed promptly?
- 04How are handwritten medicine changes for discharge-to-assess residents checked and countersigned?
- 05How do you record people's spiritual and cultural wishes for end of life care?
This was a planned, unannounced inspection covering all five key questions, including both the premises and the care provided. This explanation was written from the published report of 18 April 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Sebright House Care Home
5 rated inspections over 7 years: the service has improved, from Requires improvement to Good.
- May 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- March 2019Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2015Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- February 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 14 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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