Sibbertoft Manor Nursing Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always ensure people’s care and treatment plans were effective. Pre-admission assessments covered all key areas needed to ensure the service could meet people’s needs safely and effectively. One relative told us, “The pre-assessment was amazing. We contacted them, they instantly invited us up and we were made to feel very welcome. The manager came out to the house and discussed mum’s needs.” Staff knew how to access people’s care plans on the care system and demonstrated good knowledge of people’s individual needs, including dietary and communication needs. Information within care plans for specific health conditions, such as epilepsy and diabetes, was detailed and clear. People using the service and their relatives told us they were involved in assessing, planning, and reviewing care, which helped ensure support was person-centred and met their needs.
People were involved in planning their care and records were reviewed regularly. However, we found inconsistencies and a lack of details in some records. For example, a person’s records had not been updated to reflect they were not longer using bed rails. This inconsistency created a potential risk that staff unfamiliar with the person could follow outdated guidance and use bed rails unnecessarily without other appropriate monitoring. We also found wellbeing checks carried out at night or when people were in their rooms were not applied consistently, with different intervals recorded without clear explanation in relation to the clinical need or person’s choice. This meant we were not assured the frequency was based on people’s assessed needs. The provider told us during the assessment they would review records in relation to our findings.

People's care and treatment were planned with them and reflected what was important to them. A range of risk assessments were used to monitor people's health and wellbeing, including MUST, Waterlow, choking and falls assessments. Where risks were identified, action was generally taken, such as referrals to dietitians and the use of pressure-relieving mattresses. However, we found some gaps in recording and care planning. One person's catheter care plan did not include important information such as the reason for the catheter, catheter size, and catheter change dates. Records did not always clearly show urine output when catheter bags were emptied. We also found inconsistencies in records and staff knowledge relating to modified diets. In some records, the diet recorded on meal charts did not always match the person's assessed dietary needs or was recorded inconsistently. This meant staff did not always have clear and reliable information available. Some people had prescribed daily fluid targets. Records showed these targets were not always achieved, and there was limited evidence that this had been recognised, reviewed or acted upon. This meant monitoring systems were not always effective in identifying and responding to potential risks relating to hydration. While staff generally knew people's needs and care was usually provided correctly, improvements were needed to ensure records were accurate, consistent and detailed enough to support safe and effective care.

The provider worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The provider worked well with a range of health professionals, including GPs, the Speech and Language Therapy (SALT) team, dietitians, and the Tissue Viability Nurse (TVN). Staff told us communication within the service was good, and that information about people’s needs was shared promptly both internally and with external professionals when required. Staff said they had easy access to care plans, which supported consistent and safe care. Daily handovers and regular meetings with heads of departments were part of routine practice. Staff told us they felt well supported and described a positive team culture that included leaders. A relative told us, “They’re very switched-on regarding health and safety. It seems very slick; everybody knows what to do. It’s good teamwork.”

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support. People had access to healthcare services and were supported to attend routine health appointments such as optician and dental visits. GP rounds took place weekly and regular medication reviews were carried out. People’s vital signs were monitored, weights were tracked, and referrals were made when concerns were identified. The provider also supported people to take part in a range of activities, including day trips, live music, and games. Systems were in place to support people to make choices about meals. Pictorial menus and written meal options were available, and people were able to change their choices on the day if they wished. Fresh fruit and snacks were also available throughout the day. People gave positive feedback about the support they received. One person told us, “I would say they’ve got a very good understanding of my health conditions. They've become specialists in old age treatment. Their whole attitude is very good. I feel very included.” However, people’s experiences were not always the same across the service at the time of inspection. While systems were in place to support choice and flexibility around meals, some people chose their meals in advance for the week and the dining atmosphere varied between different areas of the home. Despite this, people were able to change their meal choices if they wished, and we saw staff supporting people in a kind and respectful way during mealtimes.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and Consistent.

Staff showed a good understanding of people’s individual needs and how to support their health and wellbeing in everyday care. Records showed staff worked closely with external professionals, such as health and social care services, to coordinate care and make sure people received the right support at the right time. Accidents and incidents were reviewed each month to help identify any patterns or learning.

There were systems in place to monitor people’s health and wellbeing. However, these systems were not always effective in identifying or responding promptly to emerging concerns. For example, bowel and continence care plans did not consistently include clear escalation guidance or instructions for staff. In some cases, bowel charts showed people had not opened their bowels for several days, but there was no evidence that this had been escalated or acted upon.

When we brought this to the attention of the provider, they took immediate action and reviewed their practice to strengthen monitoring and escalation processes.

The service planned both clinical and non-clinical outcomes with people, focusing on what mattered to them and their personal goals. For example, one person was supported to complete a glider flight in 2025. One person told us, “They are very vigilant.” Another said, “If I feel ill, the staff take notice.”

The provider did not always ensure people’s rights around consent were fully recorded in line with the Mental Capacity Act. Mental capacity assessments and best interest decisions were not always decision-specific or clearly documented. Mental Capacity Assessments (MCAs) and Best Interest decisions had been completed for some decisions relating to people’s care and treatment. However, these were not always decision-specific and did not consistently cover all relevant areas of care, such as CCTV monitoring, use of sensor mats, bed rails, care and treatment decisions, and photography and information sharing. Records were inconsistent, with some people having appropriate assessments and best interest decisions in place while others did not. In several cases, the records lacked sufficient detail to clearly demonstrate how decisions had been assessed and agreed in line with the Mental Capacity Act. CCTV was in use in communal areas, but where people lacked capacity, appropriate MCA and Best Interest decisions had not been formally documented to support this. When this was discussed during the inspection, leaders acknowledged the gaps in documentation and took immediate steps to review and strengthen consent processes and legal compliance. Our observations showed that, in practice, staff supported people to express their views and respected their day-to-day choices. Staff had received training on the Mental Capacity Act and understood the importance of supporting people to make their own decisions wherever possible.