Archived: Seahorses

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. This key question has still been rated requires improvement. This meant the management and leadership was inconsistent. Leaders did not always support the delivery of high-quality care. The service remained in breach of regulation in relation to governance.

This service scored 57 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Leaders promoted a holistic approach at the service, which promoted a positive culture and person-centred care. There appeared to be an open and transparent culture at the service. Staff spoke positively about the culture of the service, and people appeared happy and content.

There was a new manager at the service following the last inspection, and although leaders were compassionate and inclusive, they had not identified or made the relevant improvements in relation to risk management, recruitment, choice and control, and overall governance. However, they had identified and made some improvements at the service, by promoting a positive culture and holistic way of working, and around capacity and consent. Staff spoke positively about the new manager and nominated individual. People and their relatives praised the leaders within the service, and felt they were approachable and responsive. One person told us they felt any concerns would be responded to appropriately

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff felt confident concerns would be appropriately addressed. There was a Freedom to Speak Up Policy in place and there was a recorded point of contact for staff to refer to if they had any concerns. Staff knew who this nominated person was. The policy also contained up to date details of the local authority safeguarding team and the Care Quality Commission.

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 manager told us, “We have a very diverse group of staff. We welcome everyone regardless of their ethnic background, colour, religion or sexuality. New staff are recruited using a values-based approach.” The manager also provided an Equality and Diversity policy which stated, ‘Seahorses Care Home Ltd will promote awareness and provide appropriate training on recognising and avoiding discrimination, harassment, victimisation and promoting equal opportunities and diversity in the areas of recruitment.” We saw evidence to demonstrate all staff had completed training in equality and diversity.

The provider still 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. Information was not shared securely with others when appropriate, and the manager was not aware of their responsibility to do so. We found there was 1 recorded safeguarding incident between 2 people living at the service which had not been reported to Care Quality Commission (CQC), in line with the provider’s legal responsibilities to do so. The manager told us they did not realise they needed to notify CQC due to safeguarding closing this down, but told us they would ensure all incidents would be notified to CQC in future, where appropriate. Audits were taking place at the service; however these were not always effective. For example, the provider’s medicines audits had not identified the gaps in relation to the administration of medicines for people, nor the missing ‘as required’ medicine protocols and the missing risk assessments for required medicines, such as paraffin-based products, for those that used such products. Recruitment processes and practices continued to not be followed consistently in line with the requirements of legislation. Risks to people using the service continued to not always be identified by the service and therefore these were not appropriately mitigated. The service continued to not have effective oversight in the areas identified in this inspection, such as risk management, recruitment, and choices for people.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. The provider had not considered engaging with the local SALT to ensure modified diets for people were correct and appropriate. Health professionals we spoke with felt there had been some improvements since the last inspection, but felt further work was required in some areas, such as ensuring the service proactively identifying concerns. However, the manager told us, “We welcome and seek out input where we have any concerns. We have created a survey for outside professionals and hope to have collated responses by the end of March… We have daily input from the district nurse team to give insulin to a resident and to review dressings. We also have a weekly GP round. We feel that we are always open, honest and transparent when we give or receive information and carry out any actions that have been requested.”

Systems and processes were still not always effective to support learning, improvement and innovation. For example, audits did not always identify areas for improvement, such as in relation to infection control risks and discrepancies in care plans. Additionally, we found that although some improvements had been made, enforcement notices had not been fully met by the provider and we found similar concerns at this inspection, in relation to risk management, recruitment, choice and control, and governance systems. This meant the provider had not fully learnt from the last inspection, which put people at continued risk of harm. However, staff felt there was a learning culture within the service. One staff member told us, “We always have meetings or [management] call our attention, [managers ask if they can speak with us], this can be within a group or individually.” We saw some evidence of learning through audits. For example, where issues were identified these were followed up. However, audits had not identified many of the shortfalls during this inspection.