Archived: Seahorses

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. This key question has still been rated requires improvement. This meant some aspects of the service were still not always safe and there was limited assurance about safety. There was still an increased risk that people could be harmed. The service was in continued breach of the legal regulations in relation to safe care and treatment and is now also in breach of the legal regulations in relation to staffing.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were still not always learnt to continually identify and embed good practice. This meant the provider had not always learnt from previous concerns raised which was placing people at continued risk of harm. We reviewed accident and incident records which had occurred since the last inspection. Although some learning from these incidents had been recorded, there was no evidence of how this learning had been effective or communicated to others. For example, 2 incidents which had occurred 14 days apart had the same lessons learned recorded, which was to ensure staff monitored the lounge. This meant learning from incidents was not always effective because similar incidents occurred. However, we saw some evidence of learning through regular team meetings and audits of the service, where actions were recorded and completed.

The provider did not work well with people and healthcare partners to establish and maintain safe systems of care. For example, the provider had assessed people as requiring modified diets without a formal assessment from a qualified person, such as the Speech and Language Therapist team (SALT). This placed people at risk of aspiration and choking. People had documents in place to support safe transitions into hospital should people need to attend hospital, which included information about people’s communication needs and some risks. However, we found one person’s MAR chart stated they experienced severe allergic reactions, and the cause of this reaction had not been recorded as this was unknown at the time of our site visit. Additionally, there was no information recorded about this allergic reaction within the person’s hospital transfer form. This meant there was a risk that the person could experience a severe allergic reaction from an unknown source and not all professionals would be aware of this and how to manage this safely. The provider told us, that since establishing the cause of this, they would add this information to the person’s MAR charts, however they did not inform us they would update the person's hospital transfer form or care plan, to ensure all appropriate people were aware of this.

Accidents and incidents were recorded. However, actions to reduce the risk of recurrence had not always been taken where appropriate. For example, we found 3 incidents in a 5-month period, where people had sustained unexplained skin tears and there was no evidence that these incidents had been investigated or reported to the local authority, in line with the local authority’s guidelines for reporting such concerns. Additionally, the Care Quality Commission had also not been notified of one incident where appropriate. However, there was a safeguarding policy in place which was appropriate for the service, and staff understood what it meant to safeguard people from abuse. Staff had received safeguarding training. People appeared to be supported safely during our site visit.

Care plans still did not contain adequate information to support staff to manage people’s risks safely. For example, we identified 2 people who were receiving a modified diet. These people’s care plans did not contain any information about them requiring this modified diet but was instead recorded on a spreadsheet sent to CQC. Additionally, appropriate health professionals had not been involved in an assessment or decision to ensure the assessed textures were safe for the people to eat, and this decision had been made by the home manager. This put people at risk of choking and aspiration. Staff had also not received appropriate training to support these people when eating and drinking. We also found 2 people were at risk of pressure damage, who were not being repositioned in line with their risk assessments. We raised this with the manager, who updated these risk assessments and told us these people did not require support with repositioning. However, the manager explained that one person should not be left in an armchair for longer than 4 hours, which suggested this person does require repositioning. On review of care notes, we found 5 occasions across a 3-day period in February 2025, where this person was documented as having sat in an armchair for longer than the stipulated time, which put them at risk of pressure damage, and the longest recorded time between transfers was 17 hours.The manager told us, "Our care planning and recording system ensures that skin inspections are carried out regularly during personal care interventions. All incidents of any redness are reported immediately to the district nurse team".

The environment was safe. Equipment was serviced regularly and appeared in good condition. Health and safety audits took place at the service, and these appeared to be effective, as there was evidence of actions being completed following audits, and the environment was observed to be safe.Staff were aware of their responsibilities in relation to health and safety. Fire drills were regular and staff knew what to do despite them always being directed by the nominated individual.

Staff had still not been recruited safely in line with legislation and the provider’s policy. For example, we found staff had continued gaps in their employment history which had not been explored. This put people at risk of harm through receiving care from potentially unsafe staff. Staff had been trained to the provider’s expectation, but the provider had not considered the need to arrange additional training for these specific areas of care, such as supporting people on a modified diet. People living at the service, relatives, and staff told us they felt staffing levels met people’s needs and these met the provider’s assessed minimum staffing levels for the service.

The manager promoted the ‘Gloves Off’ Campaign which was an initiative started by the NHS. This meant staff were encouraged not to wear personal protective equipment (PPE) except for when providing intimate personal care. The manager explained this was part of a holistic approach which the service promoted, and confirmed staff could choose to wear PPE if preferred. However, the risks of this approach had not been fully assessed in relation to ensuring hand hygiene was carried out effectively by all staff. This meant the service could not be fully assured staff were implementing this safely and protecting people from the risk of cross-contamination. Additionally, the service had 2 cats, and, during our onsite visit, we observed an open litter tray, which was visibly dirty in the communal lounge. Although the provider had a risk assessment in relation to pets in the service, it had not fully assessed the risk of infection to people living with dementia and had therefore not always mitigated these, such as ensuring the litter tray was enclosed. After we raised our concerns about this during the onsite visit, the provider replaced this with an enclosed litter tray and updated the risk assessment accordingly. However, staff had completed online training in infection control and there was a policy in place for infection prevention and control. We saw infection control audits took place regularly. The service was visibly clean and odour free, and people and their relatives spoke positively about the cleanliness of the service. One relative told us, “The home, the kitchen, my [relative’s] room and her toilet, which I always check, is spotless too. I am in and out of there several days a week. My sister and I were very picky about where our mother would go and Seahorses does it and does it well.”

Medicine risk assessments were not in place for some people where applicable. This meant any possible risks relating to the administration of specific medicines could not be mitigated, such as for the use of flammable creams. Additionally, protocols for ‘when required’ medicines were not always in place for some people. This meant there could be inconsistent administration of ‘as required’ medicine due to lack of protocols in place. On review of medication administration records (MAR), there were gaps in relation to the recording of ‘as required’ medicines for 3 people, meaning it was unclear whether those people had received some of their prescribed medicines. We raised this with management, who told us they would look into this, but had not yet completed their monthly audit. In addition, 1 person’s MAR record stated they could experience a severe allergic reaction, without stating what caused this. This meant there was a risk that staff would not know what could cause a severe allergic reaction for this person. We raised with management who have since established the cause of this and have asked the GP to add the result of this to the person’s records. The provider’s own audits had not identified any medicine concerns as identified at this inspection, which put people at risk of harm.