Sibbertoft Manor Nursing Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 63 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events.

Accidents and incidents are looked into and passed on to senior staff when needed. Records show that accidents and incidents are being reported as they should be. The service encourages staff to be open and honest and uses learning from incidents and safeguarding concerns to improve how care is delivered. Any actions identified are put in place and shared with staff to help stop the same issues happening again. This is shown in staff meeting minutes. The provider demonstrated an understanding of the Duty of Candour. We saw evidence that Duty of Candour letters were sent to families when incidents occurred, including when things had gone wrong. This showed the service was open, transparent, and honest with relatives.

The provider worked with people and healthcare partners to establish and maintain safe systems of care. They made sure there was continuity of care, including when people moved between different services.

Systems were in place to ensure people’s needs and relevant information was communicated when they moved between services.The hospital pack contained clear and detailed guidance for staff and external professionals, which would support a smooth transfer in an emergency. The personal emergency evacuation plans (PEEPs) kept in the manager’s office were up to date and provided clear guidance for people, staff, and external professionals responding to an emergency evacuation of the service. Staff knew where to access the hospital packs and PEEPs when needed.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Systems and processes were in place to protect people and to identify, report, and monitor safeguarding concerns and Deprivation of Liberty Safeguards (DoLS). Safeguarding policies were in place and staff understood them. Staff were able to recognise signs of abuse and explain what action they would take if they were concerned someone was at risk. Both staff and leaders had completed safeguarding and Deprivation of Liberty Safeguards training.

The provider generally worked with people to understand and manage risks while respecting their choices and preferences. Risk assessments and care plans were in place to support staff in managing risks. The provider used a risk screening tool to identify risks and assess how likely and serious they were. Information was available to help staff recognise and respond to specific risks, such as the signs and symptoms of high or low blood sugar in people with diabetes. Care plans and risk assessments were regularly reviewed and monitored.

The provider did not always identify and manage environmental risks in a timely way. Although most health and safety systems and checks were in place, some environmental risks had not been properly assessed or addressed.Effective fire safety arrangements were in place. Clear signage was displayed throughout the service to help keep people safe. Information about people's needs in the event of an emergency evacuation was up to date and easily available to staff. The service was clean, well maintained and free from unpleasant odours. Health and safety checks were up to date, and the provider carried out regular maintenance checks and audits. The provider complied with most health and safety requirements, including regular Portable Appliance Testing (PAT), servicing of fire alarms and panels, inspection of fire extinguishers and emergency lighting, and LOLER testing of lifts and equipment.During the inspection, we identified some environmental safety concerns. Risk assessments had not been completed to assess whether freestanding wardrobes needed to be secured to the wall based on the level of risk to people using the service. We also found a sharps bin left on top of an unattended medication trolley in a communal dining room for a prolonged period. The provider took immediate action to address these issues.

The provider ensured there were enough qualified, skilled, and experienced staff to meet people’s needs. Staff received appropriate support, supervision, and ongoing development. People and their relatives told us there were enough staff available and that their needs were met reliably. Nurses were supported to keep their professional skills, knowledge, and practice up to date. There was evidence NMC Pins were checked for nurses. Staff received regular supervision, training tailored to people’s specific needs, and refresher training to ensure they followed current best practice. A training lead monitored staff training compliance, arranged additional training when needed, and delivered regular workshops.

We found the provider had not viewed the original criminal records certificate for a staff member with a DBS (Disclosure and Barring Service) check on the online update service.We also found that references did not always provide full assurance that employment histories had been verified. Although the provider took immediate action to address our concerns, the failure by the provider to identify these concerns highlighted their governance processes were not robust. This meant we could not be assured safer recruitment practices were embedded in the service.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Infection prevention and control (IPC) practices were effective, and the environment was clean with no concerns identified. Staff used appropriate personal protective equipment (PPE) for the care they provided and understood how to use and dispose of it correctly. The provider had clear IPC policies and systems in place to identify and respond to infection risks, including managing outbreaks. Staff demonstrated good knowledge of these procedures. People using the service and their relatives raised no concerns about cleanliness or hygiene in the home. A person told us, “They’ve got gloves on all the time when they do my (personal) care and they keep changing them.” The service had recently experienced a respiratory infection and diarrhoea and vomiting (DV) outbreak. The provider took prompt and appropriate action to reduce the spread of infection. Public Health and the infection prevention and control (IPC) lead were informed. Families were kept updated throughout. Infection control measures were followed to help protect people and staff.

The provider did not always ensure medicines were managed in a way that fully demonstrated safe practice and met people’s needs and preferences. While medicines were generally managed safely and systems were in place, recording of refusals or omissions and escalation processes were not always clearly documented, and audits had not consistently identified these issues.

The provider had a clear and robust medicines policy, which reflected best practice guidance, including guidance from NICE. Medicines were generally well managed, and no widespread concerns were identified. Electronic medication administration records (eMAR) were in use, although some staff would benefit from further training to use the system effectively. Bottles were clearly dated when opened. Protocols for “when required” (PRN) medicines were mostly clear and appropriate, but those that allowed for variable doses, such as “take one or two tablets,” required more detailed guidance.

Medication administration records were fully completed. However, when medicines were refused or omitted, records did not consistently explain the reason or whether staff attempted to administer the medicine again. Instead, only codes were used. There was also no clear evidence that regular medicines not given due to refusal or omission were escalated to the GP when required. For example, one person had not received their regular paracetamol for 7 days because they were asleep or refusing, but there was no evidence of follow-up action to address this. This indicated risks and potential risks to people.

Staff received training and were regularly assessed as competent. Controlled drugs were stored, recorded, administered, and disposed of safely, with regular checks in place. Stock checks completed during the inspection matched the service's records. Governance and audit arrangements were in place to oversee medicines management. Regular monthly medication audits were completed, and where shortfalls had been identified, actions had been taken to improve practice.

However, the monthly medication audit had not identified the issues found during this assessment. This showed that the current audit tool was not fully effective. The provider acknowledged this and agreed that the audit process would be reviewed and strengthened to ensure it covers these areas and identifies concerns more effectively in future. A person told us, “My meds are always on time, and they make sure I swallow them.”