Seaton Hall Residential 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 assessment we rated this key question good. At this assessment the rating has changed to 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, person-centred care.

The service was in breach of legal regulation in relation to the governance at 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, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Governance systems were not effective in supporting the provider’s vision of maintaining high standards of care, by assessing, reviewing, and meeting the physical and psychological needs of the individual residents. The issues we identified during our inspection had not been recognised during the completion of audits. A solution to the ongoing problems with the electronic care planning system had not been sought prior to our inspection. The provider’s quality assurance systems did not offer a strong oversight of the service and did not support the registered manager in their role.

Staff were complimentary about the leadership at the service. Staff members we spoke with told us the registered manager was approachable, and any issues raised were dealt with.

The provider had inclusive leaders at all levels who understood the need for delivery of good quality care and support care.

The service did not always keep up to date with relevant changes, and this impacted on the safe delivery of care and support. For example, gaps in recruitment records and lack of robust protocols for use of agency staff, and the monitoring and recording of people’s money.

The registered manager was open and honest throughout the inspection, and when issues had been highlighted, set about resolving them and putting solutions in place immediately, or sought help from an external source. The provider did not have effective leadership or oversight, we found their audits did not support good leadership.

Staff spoke positively about the registered manager and the provider. A staff member told us, “I feel supported by [registered manager], and we see [the provider] monthly and we can speak with him.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff had access to whistleblowing information and were able to raise concerns in team meetings or supervisions. When concerns were raised, the registered manager dealt with these confidentially, conducted an investigation and lessons were shared and acted on.

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.

Staff had completed equality and diversity training. Staff feedback was positive about the support they received from the registered manager. Following the introduction of the electronic care planning system, staff were required to use a handheld system to record interventions. The registered manager actively supported staff to master the system and identified staff who needed additional support. Reasonable adjustments were put in place to support staff to carry out their roles.

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.

Quality assurance systems were ineffective; they lacked detail to support staff to identify gaps in the delivery of care. Record keeping throughout the service was poor and DBS monitoring and training records were not accurate or up to date. The concerns regarding the cleanliness of the service, IPC and ongoing issues with the electronic care planning system had not been recognised prior to the inspection. The quality assurance system contained conflicting information, compared to the evidence we found during the inspection. For example, the provider’s monthly audit stated, ‘staff DBS matrix viewed’ with a tick for ‘yes.’ However, we found gaps in record keeping.

New practises introduced at the service, such as the use of agency staff, were not added to the quality assurance system. This meant the provider did not have oversight of these matters.

The registered manager was responsive to the issues highlighted during the inspection and set about resolving them immediately.

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 service worked in partnership with health and social care professionals to achieve good outcomes for people. A professional told us, “Seaton Hall work in partnership with other agencies, are always completely transparent in their approach, and make referrals to other agencies, when needed.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. Quality assurance systems were ineffective and did not identify areas for improvement. Issues could not be analysed which did not allow for learning opportunities to improve the quality of care provided.

The provider failed to ensure safeguards were in place to reduce the risk of financial abuse. People’s financial records only required one staff signature to record transactions, and audits were completed by the same staff team. The registered manager immediately added additional safeguards to the process. This risk had not been recognised via the provider’s quality assurance systems. The registered manager advised no concerns had been raised about the management of people’s financial records but confirmed documentation would now require an additional staff signature.