Sebright House Care 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 inspection we rated this key question good. At this inspection 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 58 (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 make sure people’s care and treatment were effective.

Where some health conditions had been identified in people’s assessments, the provider had failed to incorporate this into other documents such as a care plan or risk assessment. For example, one person had a pacemaker but there was no supporting care plan. Reviews of care plans had not always identified discrepancies or conflicting information. For example, 1 person’s falls risk assessment had been reviewed on the 28 August 2025, but the level of risk had not been correctly identified. This meant staff did not always have up to date guidance to ensure people were supported in line with their personal preferences or changes in need.

Assessment records did not always reflect how people or their relatives had been engaged in the process and decision making. One relative told us, “I wasn’t really involved in [Name’s] care needs. It just happened; they didn’t involve me.” Another relative commented, “They might review [Name’s] care, but they don’t communicate that to us. We shouldn’t have to ask them.” A third relative said, “[Name] came from hospital and the plan was carried over so there was no update initially, but there has been since.”

The provider did not always deliver care in line with legislation and current evidence-based good practice and standards.

There was a lack of understanding across managers and staff on how to deliver care in line with national standards and best practice guidance. The International Dysphagia Diet Standardisation Initiative (IDDSI) Framework isa global, standardised system of 8 levels (0-7) that describes food textures and drink thicknesses for people with dysphagia (swallowing difficulties).It aims to improve people’s nutritional safety by providing a common language for everyone to use. Staff were not using the IDDSI framework when describing people’s diets, thereby increasing nutritional risks due to the use of inconsistent language for textures and drinks.

Information about people’s dietary needs was not always accurate. For example, the list in the kitchen of those people who required specialised or modified diets did not include a person who was gluten intolerant.

Meals were delivered pre-prepared from a central kitchen. One person’s care plan stated they required a ‘puree’ diet due to their risk of choking. Their meal was delivered in a container labelled ‘puree meat’ and was the only option available to the person. On the day of our inspection a gluten free meal had not been sent for the person with a gluten intolerance. A member of kitchen staff told us they would make the person a sandwich using ‘normal’ bread because they had run out of gluten free bread. This put the person at risk as small amounts of gluten can trigger symptoms, including diarrhoea, fatigue, and bloating.

Overall, people and their relatives raised no concerns about the availability of drinks and the quality of the meals served within the home. Comments included: “The food is alright, there is a choice I think”, “They told me [Name] is not drinking enough. They do encourage her, the d inks trolley comes around all the time, and they also give her fruit and biscuits” and “The food is suitable for him, it is all soft food. He always has a drink with him, tea and soft drinks.”

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.

Processes ensured effective communication with other healthcare professionals, so they had information about people to support their visits. One healthcare professional told us, “We have a well-established communication channel which allows the nursing staff to contact us about any queries they have with the residents, and this is always done in a timely fashion.”

Clinical and care staff described the processes in place to ensure important information was shared. This included a handover between shifts to ensure staff had up to date information about people.

The provider supported people to manage their health and wellbeing to reduce their future needs for care and support.

The GP carried out weekly ward rounds at the home either in person or virtually and people were referred to external healthcare professionals when a need was identified. For example, speech and language therapists and dieticians. One staff member explained, “If we see anything we tell the clinical lead or the manager, for example, say a resident is not well. The clinical lead checks and if needed gets the doctor or tells us to keep a close eye and report back.”

People were also supported to access routine health appointments, such as, access to optician and chiropody services. One relative told us, “They do [Name’s] nails regularly and he had an eye test 2 weeks ago. He saw an audiologist yesterday.”

However, we found people’s emotional and social health and wellbeing would be further improved by increased access to activities and engagement both at home and in the local community. We have further reported on this in the caring key question in this report.

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 andconsistent, or that they met both clinical expectations and the expectations of people themselves.

Care plans did not always provide sufficient information to maximise positive outcomes for people. For example, 1 person’s care plan recorded they had dementia but did not specify what type of dementia. Each type of dementia has different symptoms, treatments and support needs. It is therefore important staff have this information to enable them to manage the condition effectively and plan person centred care. Another person’s care plan stated they were known to become anxious and agitated around 4.00pm. There was no information to inform staff of the possible signs the person was becoming anxious or how they should support the person to improve their outcomes at times of distress. A third person’s nutritional care plan stated their food and fluid intake needed to be recorded in their best interests. A review of supplementary records with the provider’s area support manager confirmed the person’s food and fluid intake was not being recorded or monitored by staff. This meant a need to encourage the person to drink or eat more might not be identified thereby placing them at increased nutritional risk.

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Care plans considered people’s capacity and their ability to consent to their care and make decisions about the support needed. However, mental capacity assessments were not decision specific and did not consistently evidence people had been given the best opportunity to make their own decisions.

When decisions had been made in people’s best interests, the requirements of the Mental Capacity Act 2005 had not always been followed. Where appropriate, family members and others involved in people’s care have a right to be involved in decision making because they often have a better understanding of the person’s views and preferences. There was a lack of evidence to show clear and meaningful meetings were held to discuss best interest decisions for people. For example, in relation to the administration of medicines covertly (disguised) in food or drinks.

During the inspection some people’s bedrooms were locked and they were unable to access their bedrooms independently. The decision as to whether a person’s bedroom door was locked was made by a senior member of staff. This member of staff confirmed meetings had not been held with the person or others involved in their care to ensure this restriction was in the person’s best interests. The provider had failed to have effective oversight to ensure the restrictions were necessary and people were not unlawfully restricted.

The area service manager acknowledged mental capacity assessments and the documentation to support best interest decision making needed to be developed and improved. On the second day of our inspection the new manager had already started to review mental capacity assessments and best interest documentation to ensure legislative requirements were being met.

Staff understood the need to seek people’s consent before providing care or support. One staff member told us, “You always ask the resident and tell them what you are going to do. Even the residents who can’t tell you will let you know. Some will smile or shout. We just know our residents and what they want.”

The provider had made appropriate referrals where people were potentially being deprived of their liberties.