Seaton Hall Residential 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 assessment we rated this key question good. At this assessment 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 people’s safe care and treatment and the governance at the service.

This service scored 50 (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. Concerns about safety were not always identified and resolved.

The service had processes to gather and assess information from accidents and incidents and safeguardings. The registered manager carried out thorough investigations into any raised safeguarding concerns and referred them to the appropriate authorities. However, concerns we identified regarding cleanliness, Infection Prevention and Control (IPC), and lack of protocols for the use of agency staff and the safe management of finances had not been raised by any staff member. The registered manager took immediate action to address the issues during the inspection.

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.

The service worked with a range of health and social care professionals ensuring people received joined up care and support. Staff quickly recognised changes in people’s care and support needs and made referrals to appropriate services, including the falls team and speech and language therapy team.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Safeguarding processes were in place to record and investigate raised concerns and these were shared with the local authority safeguarding team. Staff had completed safeguarding training and knew how to raise concerns. People and relatives told us staff treated people well and people felt safe at the service. One relative said, “[Person] has been here about 6 years, and I feel it’s absolutely safe.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks were not always recognised and mitigated. One person had a specific piece of equipment to support them to remain healthy. No risk assessment was in place, and the associated care plan did not effectively detail how staff were to ensure the equipment was used, cleaned and maintained. There was no information to support staff to identify the risks linked to the use of the equipment and take appropriate action to ensure the person remained safe.

The provider had not always assessed and managed risks relating to people's specific health conditions. Care plans contained incorrect information regarding potential risks relating to people's health needs and how to mitigate these. For example, for all people diagnosed with diabetes care plans reported, ‘10-15 minutes following a hypo, [Person]’s blood glucose should be checked, and if the level is still too low, more sugar should be consumed.’ The registered manager told us that this was incorrect as staff are not trained to take and check people’s blood glucose.

The electronic care planning system had prepopulated text in the care plan and the registered manager was not able to delete this information. The registered manager has approached the software provider to address this matter.

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

Routine health and safety checks were not effective; they did not record all appropriate information to enable the service to recognise when action was required. For example, records for the monitoring of water temperatures only had a tick rather than a record of the measured temperature. Window restrictor records were not robust and did not support in ensuring appropriate checks were conducted. For example, records did not report if the window opening was restricted to 100 mm or less. Our review of the window restrictors confirmed the requirements were met.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff received effective support, and supervision and development.

The deployment of agency staff was unsafe. The registered manager did not obtain pen profiles of agency staff prior to them working in the service. This meant staff could not confirm the identity of the agency staff, and if they had the appropriate training and DBS status. The registered manager said that agency staff received an induction but there was no record of this taking place.

The service did not have effective systems to record and monitor Disclosure and Barring Service (DBS) checks. The DBS monitoring tool had gaps and did not record if additional checks had been conducted in line with the DBS updating service requirements. This failing had not been identified via the provider’s quality assurance process.

On the second day of inspection the registered manager ensured that all DBS information was gathered and recorded appropriately, and processes for the use of agency staff had been created.

People were supported by a consistent staff team. Staffing levels were determined by the needs of the people who used the service.

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

Audits completed by a range of staff reported that the environment was clean and compliant with IPC measures. On the first day of inspection, we found areas of the home, including bath/shower rooms and toilets, were dirty. We found sinks and baths had stains, shower chairs were rusty with layers of dirt, toilet brushes held debris and flooring had lifted.

Safe IPC practises could not be followed as areas were difficult to clean appropriately. For example, tiles had been painted, and handrails had chipped areas. Following feedback, the registered manager sought advice from the local NHS IPC Nurse and improvements had been made by the second day of inspection. New documentation had been introduced to ensure thorough checks were conducted with clear assigned roles of responsibility.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were managed safely. Medicines administration records were accurate and complete. The service followed guidance for the receipt, storage, administration, and disposal of medicines. People received their medicines as prescribed. Staff were attentive to people’s needs and offered support when administering medicines.