Sibbertoft Manor Nursing Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Requires Improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

During this assessment we identified a breach of regulation relating to governance.

This service scored 61 (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 the service’s vision, values, and culture were consistently embedded in day-to-day practice, and leadership oversight was not always sufficiently structured to support a coordinated approach to meeting people’s needs.

Leaders and staff demonstrated a clear understanding of the provider’s vision and values and how these supported the delivery of high-quality, person-centred care. These values were reflected in the provider’s policies and procedures. Feedback from people and their relatives was mostly positive and reflected a caring and respectful culture. Staff spoke positively about the culture of the home and described it as supportive and welcoming. One staff member said, “From the moment I walked in I knew it was the place for me to work.” Staff said they were encouraged to share ideas and felt listened to. Although the vision and values were well described, they were not always fully embedded in everyday practice. At times, the way the service operated did not consistently demonstrate a clear and coordinated approach to meeting individual needs. Some aspects of day-to-day management required greater structure and consistency. The registered manager was open about these areas and recognised that further work was needed to strengthen team alignment and improve oversight. The provider was working to an action plan, and several of the areas identified during our assessment had already been highlighted internally, with improvements underway. Daily meetings with heads of departments supported communication and helped leaders keep track of key issues within the service.

Feedback about leadership and management was positive from staff, people, and their relatives. Staff described leaders as approachable and supportive and said this had a positive impact on the atmosphere in the home. One staff member told us, “I love working here. It is a very inclusive place with a friendly, warm, and homely atmosphere.”

Senior leaders, including those not involved in the day-to-day running of the service, had a good understanding of the people living at the home and their needs. For example, the Director knew people well and was described as reasonable and easy to approach. The registered manager was well regarded, and their leadership was reflected in the way the service was run. The registered manager and deputy manager worked closely together, and there was clear communication between the provider and the management team.

Overall, leaders and staff shared a clear commitment to making the home a welcoming and homely place for people to live and work.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The provider promoted an open and positive culture where people and staff felt able to speak up and be heard. Regular meetings were held with people using the service and their relatives to encourage feedback and discussion. Staff told us they felt confident raising concerns and knew how to use the whistleblowing process if needed. They said concerns would be taken seriously and acted on, and that issues could also be raised externally with the local authority or the CQC if required. The provider actively promoted whistleblowing and had a Freedom to Speak Up Champion in place. Policies clearly explained how to raise concerns, including how to do so anonymously and how to contact external organisations. Staff said they could approach the registered manager with any concerns. Information posters about complaints and whistleblowing were clearly displayed on noticeboards around the home.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had champion roles in place, such as falls and Medication Champions, which helped staff develop their knowledge and skills. Staff told us this made them feel more confident and supported in their roles.

Where possible, work patterns were adjusted to support staff’s personal circumstances, for example through changes to working hours. This helped staff feel valued and able to balance their work and home lives.

Staff spoke positively about working for the provider and described good teamwork. Leaders promoted equality of opportunity and fair treatment for all staff, supporting an inclusive and respectful working environment.

The provider did not have effective governance and oversight systems to ensure risks, performance, and quality were consistently monitored. Audits and checks had not identified several issues found during the inspection, which meant leaders did not always have clear assurance that safe and compliant practices were maintained.

The provider had governance systems in place to monitor the service. Daily “10@10” meetings supported communication across departments and helped leaders maintain oversight. Formal governance meetings were also held regularly to review areas such as incidents, complaints, audits, DoLS, and action plans. However, governance processes were not always fully effective. Internal audits and monitoring had not identified some of the shortfalls found during the inspection, including gaps in care documentation, inconsistencies in the meal charts, eMAR records, and Mental Capacity Act and DoLS processes. The provider did not fully assure themselves audits and checks were robust as they did not monitor these i.e. no evidence these documents were reviewed. This meant leaders did not always have full assurance that quality and compliance were consistently maintained. Leaders were open about these gaps and acknowledged that oversight and follow-up needed to improve. During the inspection, the registered manager and Director outlined plans to strengthen audit systems, improve monitoring, and share responsibility more clearly to support better long-term oversight. However, these changes required implementation and embedding into practice. The provider also had a business continuity plan in place to manage emergencies, such as fire or infectious outbreaks, which supported the sustainability of the service.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The provider worked in partnership with the local community and other services to support people’s wellbeing. The home hosted events, such as an annual summer fete, which were open to the local community and helped people feel connected and involved.

The service worked closely with a range of health and social care professionals to meet people’s needs. Feedback from visiting professionals was positive. Paramedics told us staff knew people well and described the home as “one of the better homes they visit.” A speech and language therapist said, “From the moment you ring Sibbertoft to when you arrive you feel that staff have the time to speak with you. You are always welcomed, greeted positively, and feel supported by the team.” During the inspection, we observed professionals being warmly welcomed, which supported effective partnership working.

Records showed the provider was engaging with the integrated care board and the local authority to support service improvement. The activities team also helped people maintain links within the home and the wider community, supporting a sense of belonging.

The provider did not always ensure learning and improvement were embedded into practice. While leaders were open to feedback and engaged with external networks, identified issues were not always addressed or sustained in a timely way. Leaders demonstrated an understanding of best practice guidance, and there were systems in place to support learning from incidents, audits and feedback. The registered manager described how they sought to keep their knowledge up to date, including attending local authority forums and being members of the Northamptonshire Association of CQC Registered Care Providers (NORARCH), which supported shared learning and sector awareness. A relative told us, “They learn from everything.” However, learning systems to drive improvement were not always effective. For example, not all the concerns we found during the assessment had been identified by the provider’s internal audits and the required improvements were not recorded on their service improvement plan. At the end of day two of the assessment, we raised concerns about key risks to people, including the consistency of reporting and oversight of nutrition and bowel monitoring charts. When we returned to check on these specific risks, although some improvements had been made, we found similar gaps and inconsistencies. While leaders were open and receptive to feedback, We could not be assured that the governance arrangements at the time of the assessment would lead to sustained learning and improvement. We will check on improvements at our next assessment.