Sebright House Care Home

This inspection was brought forward following a review of the information we held about the service and concerns about the management of risks. We found 2 breaches of the regulations in relation to safe care and treatment and good governance.

During this inspection we spoke with people who lived at the service, their relatives, staff, the newly appointed manager, the area service manager, the nominated individual and sought feedback from other healthcare professionals. We looked at care plans, recruitment files and quality assurance records.

The provider’s audits were not sufficiently detailed to ensure a robust system of checks and did not cover all aspects of service delivery. Where checks were delegated to others, there was limited oversight to ensure they accurately reflected standards of care. Improvements were required to ensure there was a culture of listening and learning from staff experiences. Ineffective monitoring meant the provider did not have an accurate picture of the care being delivered and did not support a learning approach.

There was limited evidence people and their relatives had been involved in developing and reviewing risk management plans. Where people could demonstrate distress or anxiety, care plans did not always contain sufficient detail to ensure staff responded consistently to promote positive outcomes. There were enough staff to keep people safe, and staff understood their role in reporting concerns about people’s health and wellbeing. However, staff were not always clear about how they could escalate concerns if appropriate action was not taken. The provider was not proactive in ensuring staff had the training and support they needed for their role and remained up to date with best practice guidance. People received their prescribed medicines, but improvements were required in the management of time specific/sensitive and ‘as required’ medicines. There was a lack of effective maintenance of the premises which increased the risk of the spread of infection.

Staff were seen to be caring with people and to speak to them in a kindly way. However, care plans lacked information to enable staff to get to know people well and it was clear some staff felt more confident and comfortable to engage proactively with people. There were limited meaningful activities to promote people’s emotional and social wellbeing, but this had been recognised as an area for improvement and action was being taken at the time of our inspection. Where people lacked capacity to make their own decisions, there was a lack of evidence to show clear and meaningful meetings were held to discuss best interest decisions for people.

There were processes in place to support communication with other healthcare professionals and to ensure their advice was known and implemented into care plans.

There was no registered manager at the time of our inspection. The provider had appointed a new manager who had previously been the registered manager at Sebright House Care Home and knew the service well. The new manager had already identified and prioritised improvements that needed to be made and demonstrated a commitment to improving standards within the home.

We have asked the provider for an action plan in response to the concerns found at this inspection.