Sibbertoft Manor Nursing Home

This was a routine assessment of the service. The assessment included observations of care, speaking with people and relatives, interviews with staff and managers, and a review of care records, policies and monitoring systems.

Overall, people were supported by staff who were kind, respectful and attentive. Staff knew people well and demonstrated a good understanding of their needs and preferences. People told us they felt safe and valued the care provided. Safeguarding systems were in place, staff had received relevant training, and incidents were recorded and reviewed to support learning and improvement.

The environment was clean and well maintained, and infection prevention and control practices were effective. Fire safety systems were in place and information to support emergency evacuation was accessible. During the assessment, some environmental risks were identified, including unsecured wardrobes and a sharps bin left unattended on a medication trolley. The provider took immediate action to address these issues.

There were enough staff available to meet people’s needs, and staff received regular training and supervision. Nurses were supported to maintain their professional registration and skills. However, recruitment processes were not always fully robust. Records did not always evidence that original DBS certificates had been seen, and references did not always fully confirm employment history. These issues were addressed once identified.

Medicines were generally well managed and staff were trained and assessed as competent. However, improvements were needed in recording refusals or omissions and ensuring follow-up action was clearly documented. Medication audits had not identified some of these issues, which showed the audit system required strengthening.

People’s needs were assessed before admission and care plans were reviewed regularly. Staff demonstrated good knowledge of people’s health conditions and worked with external professionals such as GPs, dietitians and speech and language therapists to support people’s wellbeing. However, some care plans and risk assessments lacked detail or consistency, particularly when people’s needs changed. Improvements were needed to ensure care documentation and monitoring systems were consistently accurate and effective.

Leadership was viewed positively by staff and relatives, and the service promoted an open culture where people felt able to speak up. However, governance systems were not always effective in identifying shortfalls. Some issues found during the assessment had not been identified through internal audits, which meant leaders did not always have full assurance that systems were working effectively.

Overall, people experienced caring support from staff who knew them well. Improvements are needed to strengthen care documentation, monitoring systems and governance processes to ensure quality and safety are consistently maintained.

We identified a breach of regulation in relation to good governance. This service has been rated requires improvement overall. We have asked the provider for an action plan in response to the concerns we found during this assessment.