Sebright House Care 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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 53 (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 have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

Staff recorded accidents and incidents, and these were reviewed by the manager each month. However, following accidents people’s risk assessments and care plans were not always reviewed and updated to ensure any increasing risks were identified and planned for. For example, 1 person’s falls risk assessment and care plan had not been reviewed following a fall on 22 August 2025.

Where people demonstrated their anxiety or distress through their verbal or physical responses, staff had recorded the situation and people’s reactions and behaviours. However, there was limited evidence people’s positive behaviour support plans had been reviewed following such events to ensure strategies were reflective of the person’s needs and any unmet needs were recognised.Whilst there was a monthly analysis of these incidents, this needed to be more robust to ensure all opportunities for learning and further training were identified.

Where lessons were identified, these were shared with staff during handovers or through electronic systems. One staff member told us, “The nurse does handover. We (staff) are all there. Anything specific we need to do or need to know is shared.” Another staff member commented, “Any mishap has to be written down. If a resident falls or hits staff, you report it. The manager or the clinical lead will tell you if there is anything extra you need to do.”

Relatives confirmed they had no safety concerns and were informed of any falls or accidents involving their family member.

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

Where people needed to attend external healthcare appointments, staff discussed the arrangements with people’s relatives to ensure they had appropriate support in place. The provider had processes for staff to follow to ensure people’s records were updated with any healthcare professional advice. One external healthcare professional told us, “I find that the staff follow my advice conscientiously and always follow my instructions appropriately.”

Information was shared with other healthcare professionals when people needed prompt support owing to health emergencies. This included information about any risks to people’s health, their medication and their wishes for future care.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They did not always concentrate on protecting people’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff had received training in how to safeguard people and told us they would not hesitate to report any concerns. However, we found some staff did not know the range of external organisations they could contact to escalate safeguarding concerns. For example, local authority safeguarding teams and the police.One staff member said, “I don’t know who I could go to higher than the manager.” Another staff member told us, “I would start with the manager first and then report it to CQC. That is what has been taught in the training."

Everyone we spoke with felt the service was a safe place to live in. One person told us, “Staff all seem alright and never short or rough with me.” Another person said, “It is very safe, they look after me here.” A relative commented, “They make residents safe here because of their (staff) presence.”

The provider shared concerns quickly and appropriately. Safeguarding concerns had been escalated to the local authority safeguarding team and notified to us, CQC.

The provider did not always work well with people to understand and manage risks. Improvements were required to ensure staff had the information they needed to fully understand the risks associated with people’s care and support.

Most people living at Sebright had complex dementia care needs and could demonstrate heightened levels of anxiety or agitation. Whilst people had positive behaviour support plans (PBS), they were mostly generic and did not contain sufficient detail about people’s individual triggers or diversion techniques for staff to use. Individualised positive behaviour support uses detailed and personalised information to understand the reasons behind people’s responses, rather than just reacting to them. There was a risk staff would not be able to support people in a safe way and promote positive outcomes during incidents of distress.

Risks were not always mitigated against. One person’s care records indicated they were pre-diabetic. This was not recorded in their nutritional care plan and there was no information for staff about how this risk should be managed. Another person had 1 to 1 support from staff between 10.00am and 8.00pm. On 4 occasions during our inspection, we observed this person without their 1 to 1 support in different areas of the home. This placed the person at increased risk because they were not receiving the identified level of support and observation to keep them safe.

Where care plans were in place, they often lacked detail to support effective management of associated risks. For example, in relation to falls, catheter care, skin care and the management of diabetes.

There was limited evidence people and their relatives had been involved in developing and reviewing risk management plans.

Staff were assigned specific areas around the home to make sure there was always a staff member in communal areas to keep people safe and mitigate risks.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Fire safety was not consistently well managed. Information staff and the emergency services needed to keep people safe in the event of an emergency was not up to date. The provider’s systems and processes to monitor fire safety were not effective. For example, actions identified by Warwickshire Fire and Rescue Service during a visit on 05 August 2025 had not been identified by the provider’s own checks and audits. Whilst the provider had taken some actions in response to the fire safety report, other actions remained outstanding. The provider was reminded of their responsibility to ensure risk mitigation measures were implemented until the required actions had been completed.

Some areas of the home were not maintained to a satisfactory standard, such as worn and damaged woodwork and broken door handles. On the top floor there was a wooden fuse box at floor level which was open and accessible to people. Several door guards on bedroom doors were constantly beeping which indicated they needed resetting to ensure they operated effectively in the event of an emergency. The area manager was in the process of developing an action plan to improve the safety and presentation of the service.

Staff had completed fire safety training, and some staff had recently taken part in a staged horizontal evacuation. Further sessions were planned.

Whilst the provider made sure there were enough staff, improvements were needed in training and induction processes.

Staff told us they had an induction when they started working at the service which included training and working alongside more experienced staff to learn people’s individual needs. However, in the 2 recruitment files we checked, induction booklets had not been fully completed. This meant the provider could not be assured staff had successfully completed their induction and had a full understanding of the duties and responsibilities of their roles.

The provider was not proactive in ensuring staff had the training and support they needed for their role. In a meeting in January 2025, it was identified staff had limited understanding of dementia and how to support people with a dementia diagnosis. Staff were signposted to self-directed reading about the condition and training was not organised until August 2025. This training needed to be rolled out to all staff and become embedded in their practice at the time of our inspection visit. We also queried whether staff needed more specific training in de-escalation techniques to safely respond to challenging situations. One staff member told us, “I think we need more training, that would be good. I’ve not done dementia, but another session is planned so I hope I will be on that.” Another staff member commented, “Really, we are a dementia home, and we need much, much better training. If everybody (staff) had more in-depth training, it would work better.” The new manager had identified staff training and support as a key priority in the home and booked staff on training sessions in dementia, infection control, tissue viability and recognising deteriorating health. Further training sessions were planned.

People and relatives felt staff were available when they needed them. One person told us, “I think there are a lot of staff, they are everywhere.” A relative commented, “The number of carers ensure [Name] is safe.”

During our inspection we saw there were enough staff to meet people’s needs and keep them safe. Staff raised no concerns about staffing levels. One staff member commented, “I think staffing is good. We have 4 groups so you can spend more time with the residents getting them up. You don’t feel rushed."

The provider had a policy to ensure checks were carried out to ensure the suitability of staff during the recruitment process. This included references and an enhanced Disclosure and Barring Service check. However, records did not always evidence that gaps in employment history had been fully explored prior to employment.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

There was a lack of effective maintenance of the premises which increased the risk of the spread of infection. For example, numerous door frames and skirting boards had chipped paint and splintered wood which meant they were difficult to clean.

Improvements were needed to ensure safe food hygiene practices were followed. The provider was not using the full range of colour-coded chopping boards in the kitchen. Colour-coded chopping boards are essential for food hygiene becausethey prevent cross-contamination between different food types, reducing the risk of foodborne illnesses and food allergies.Food was prepared off site, microwaved and then put in a heated trolley. The temperature of the food was checked when cooked but not at the point of serving. For food to be safe, it must be kept hot above 63 degrees centigrade to prevent bacteria growing.

We saw some positive practices to minimise cross infection. Staff had received training in infection control, and we saw them using personal protective equipment in accordance with good practice.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Improvements were needed in the administration of medicines prescribed to be given at a specific time or that required timed intervals between doses. For example, antibiotics are required to be administered at regular intervals to achieve and maintain a therapeutic level. One person’s administration record for their prescribed antibiotics demonstrated gaps of between 2.5 and 14 hours between doses.

Some people were prescribed ‘as required’ medicines at times of anxiety or distress. There was limited guidance documentation to ensure these medicines were given consistently and only as a last resort after other interventions and de-escalation techniques had been attempted. When people were given ‘as required’ medicines to support their emotional well-being, the medicine administration record (MAR) did not always evidence a clear rationale for why this had been administered.

Most medicines were stored safely. However, topical medicines applied directly to people’s skin were stored in individual cabinets in people’s bedrooms. Cabinets were not always locked in accordance with the provider’s policy which meant these medicines were easily accessible to people. This put people at risk of accidental ingestion or adverse skin reactions.

People and their relatives raised no concerns about how their medicines were managed or administered. One relative told us, “[Name’s] medication does not seem to change much. If it does, they tell me what the doctor said.”