Sebright House Care 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 inspection we rated this key question requires improvement. At this inspection the rating has remained 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 care.

The service was in breach of legal regulation in relation to the governance of the service.

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 have a clear shared vision, strategy and culture which was based on transparency, equity and engagement. They did not always support staff to understand the challenges and the needs of people.

The culture of the service did not always promote people’s individuality and meaningful engagement between staff and people was inconsistent. Staff needed more support and training to develop their skills and confidence when supporting people with complex dementia who required extra assistance to manage their symptoms and complete day-to-day activities.

Some practices did not promote a positive culture within the service. The provider had introduced regular searches of staff in response to an incident in another home in the provider group. Whilst staff knew the searches could only be carried out with their consent, some staff felt unable to refuse that consent. Comments included: “I can’t say I feel 100% valued; our bags get checked. It makes you feel not nice” and “The higher authority (provider) says we have to be checked (bag searches). We are not taking anything but if the higher authority says it has to be done, it has to be done. Of course I don’t like it.” We received similar concerns about staff having to use their personal phones and numbers to share work related information.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders had not always had the skills, knowledge, experience and credibility to lead effectively.

There was no registered manager at the time of our inspection visit. The provider had very recently appointed a new manager who they told us would submit their application to become registered with us, CQC. The new manager had previously been a registered manager at Sebright House Care Home and knew the service well. They had already identified and prioritised improvements that needed to be made and demonstrated a commitment to improving standards within the home. Staff spoke positively about the new manager. One staff member told us, “Our old manager is back; they give good support. This is very good for the staff.”

The provider’s area support manager recognised the need for more ‘hands-on’ leadership and oversight from the provider’s senior management team and commented, “I have never had to deal with this home. I deal mainly as a service support manager. I am not hands on, I don’t come in and take over from the manager.” They went on to say, “You have made me think, I need to be in this home a lot more."

The provider did not promote a positive culture where staff understood how they could speak up and their voice would be heard.

Improvements were required to ensure there was a culture of listening and learning from staff experiences. The lack of individual supervision meetings meant staff who preferred not to speak in an open forum had limited opportunity to provide their feedback about the service.

Whilst staff told us they would share any concerns with managers or senior staff, they were not always clear about levels of management and how they could escalate concerns or feedback to the provider. One staff member explained, “Let’s say you are in a meeting and want to speak out you can. Meetings are very open. If it was about a staff member you would go to the manager and tell them.” Another staff member told us, “If the manager did not listen to me that is when I would go to the CQC." There was no accessible information on noticeboards or within the staff room about the provider’s processes for supporting staff to speak up.

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.

There were procedures in place to consider staffs’ individual needs and to ensure all staff were treated equitably. Staff were encouraged to celebrate their own cultures and share those celebrations with people and their relatives. This promoted a positive culture of inclusion and diversity.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were not always effective. We reviewed quality assurance records and found issues we identified during this inspection had not been identified by the provider’s own governance processes. The service had not sustained their compliance levels since the last inspection, resulting in breaches of the regulations being identified.

The provider’s audits were not sufficiently detailed to ensure a robust system of checks and did not cover all aspects of service delivery. For example, the provider’s audits did not cover fire safety, staff training or people’s care plans and risk assessments. We identified deficiencies in all those areas.

Where checks were delegated to others within the service, there was limited oversight to ensure they were consistently completed and followed the provider’s policies and procedures.For example, manager’s checks of the service had not always been completed as required and had not identified the shortfalls in service provision we found. Ineffective monitoring meant the provider did not have an accurate picture of the standards of care being delivered.

The provider used ‘WhatsApp’ (software programme) to share information with the staff team. The ‘app’ was installed on staffs’ personal mobile phones and used to update staff with any changes in people’s needs. The provider had not done due diligence to ensure personal mobile phones were secured with a strong password or biometric lock or that there was appropriate anti-malware protection. The area manager confirmed there was no mobile device usage policy or risk assessment in place to support the use of the ‘app’.This meant there was a risk people’s personal information and confidentiality was not maintained in accordance with the provider’s legislative and regulatory responsibilities.

The lack of oversight required from the provider and management team placed people at risk of not receiving safe and effective care that was responsive to their individual dementia care needs.

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 had systems and processes to record contact with health and social care professionals and made referrals where appropriate.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was a lack of systems to ensure continuous learning and improve the care people received. The provider's own quality assurance was ineffective and had failed to identify shortfalls found at this inspection. Audits completed did not reflect required improvements or support a learning approach.

The provider had not ensured staff had received appropriate training and support for their role and were kept up to date with best practice guidance. For example, staff were not using the International Dysphagia Diet Standardisation Initiative (IDDSI) Framework to describe people’s modified diets.

The new manager welcomed our feedback and had started to take action to address the issues identified during our inspection visit.