Seymour House

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 regulations in relation to people’s safe care and treatment, safety of premises and equipment, the ways people’s medicines were managed and staff recruitment.

This service scored 44 (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 based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.There were multiple incidents recorded relating to a deterioration to people’s emotional wellbeing, as well as, incidents between people. There was some analysis completed for such events. However, it was not clear how this supported risk mitigation for people and their records were not updated accordingly. The findings did not evidence to show the actions recorded had been actioned or were effective. For example, it noted that staff needed to be more vigilant with people when in communal areas as the majority of incidents occurred within these areas. Staff needed to engage people in more engaging and enriching activities within the house and outside the house. During our visit we observed little engagement between staff and people in any meaningful activities. One of the actions was to have a new activity boards/timetables to be used for all people. During or visit, all activities were handwritten, and it was not clear if people were able to access that information as and when they wanted to choose something to do.There was little evidence that the cause of accidents and incidents had been investigated to help ensure actions would be taken to prevent recurrences.Forms completed to monitor people’s emotional wellbeing, did not provide any further analysis into causes, triggers or themes that would support more effective risk management.The deputy manager understood their role to ensure requirements of the regulation were followed and what incidents were required to be notified to the Care Quality Commission. The provider had a policy that set out the actions staff should take in situations where the duty of candour would apply. There had not been any notifiable safety incidents where duty of candour would apply.

The provider did not always work well across teams and services to support people. They did not always manage or monitor people’s safety. They did not always share their assessment of people’s needs when people moved between different services.People using the service received care from different services. However, we found not all relevant staff and services were involved in effective collaborative working to understand and meet people’s needs. For example, we found people were supported to attend their annual health checks with their GP surgery. However, some people did not have clear health action plans available on their care records. Some people’s health action plans did not contain sufficient information or detail to enable the service to continue supporting people. We found the staff attending with people noted ‘nil concerns’ during these reviews, and therefore these reviews were not always used to maximise people’s care planning, set outcomes and assess current needs.People’s hospital passports that would support them if and when they needed to attend hospital were completed after our site visit and did not always include accurate information. For example, it was recorded that people assessed as being at risk of choking, had no known risks. It was noted some people would have to be sedated to carry out certain checks like taking bloods. But it was not clear how this would be managed to ensure people were still included in these decisions.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always share concerns quickly and appropriately.People were not always appropriately supported when they felt unsafe. The service did not always have effective systems, processes and practices to ensure people were protected from risk of abuse. The management team did not ensure effective oversight of all incidents. For example, we observed an incident during our visit with a visitor. The visitor became upset with staff, and they ran towards one staff member and another person. This caused the person to become distressed and run away from the visitor. We found staff did not record this incident on this person’s care record, and did not inform the deputy manager. This did not demonstrate the person was appropriately supported following this incident. The provider did not always ensure there was effective oversight of incident reporting and appropriate procedures to be followed. This did not ensure people were protected from risk of harm or abuse. This did not always ensure people were protected to live in safety, and any concerns were reported without delay.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). The deputy manager told us they had made DoLS referrals for people to ensure appropriate legal authorisations were in place when needed to deprive a person of their liberty.

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.People with a known risk of choking were not always supported in line with guidance from Speech and Language Therapy (SALT). For example, one person’s risk assessment stated they required constant supervision during mealtimes, and small spoons are to be used to reduce the amount of food taken in one bite. We observed staff placed a whole chocolate bar in front of the person and briefly left the table. During this time, we observed the person picked up the bar of chocolate and took a whole bite from it. Staff then proceeded to support the person to eat a spoonful of rice whilst they still had unchewed chocolate in their mouth. We noted this person had previously experienced an episode of choking; therefore, the service did not ensure they applied learning outcomes from previous incidents to manage this risk.A second person’s care plan with known risk of choking stated they “may eat quickly so needs supervision whilst eating to prevent choking”. We found at least 25 examples in their daily notes where they had their meals and/or snacks in their bedroom without evidence of staff supervision.On the day of our site visit, we also observed the person was eating their meals in their room without staff supervision. This was not according to the risk assessment or guidance from health professionals. We informed the deputy manager of our findings during the assessment. However, they confirmed they were not aware this was an ongoing risk.People needed support with their emotional wellbeing when they became upset, distressed or anxious. Care records included information regarding possible causes and how to support people. However, the daily notes and staff’s practice we observed, did not evidence staff understood risk management and effective support regarding people’s emotional needs. We shared our observations with the deputy manager to take action for improvements. However, this meant the management team did not ensure effective oversight and management of people’s risk.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.We identified concerns within and around the premises which could put people at risk of harm or injury. For example, we found some fire doors were not fit for use with visible gaps in the doorframes. One of the bedroom doors was wedged open due to uneven flooring but the sign noted to keep it shut. This would not ensure people would be protected from risk of harm during a fire. Some cupboards and a loft door were left open with wires and hazardous items exposed. We shared our findings with the deputy manager on the day of our visit. The deputy manager was not aware how these doors had been left unlocked. Staff did not always record that required fire safety checks were completed and recorded at that time. Some of the records were illegible and did not ensure accuracy of the records. External fire risk assessment was not updated since people moved into the service, to ensure it was current including any new risks and effective evacuation process. Not all staff received necessary fire training including to attend fire drills, so they were aware how to evacuate promptly. We also made a referral to the fire services for further review of fire risks at the service.People had access to the garden area, but it was not tidy to ensure people were not injured. For example, contractors’ tools, bags of cement, buckets and different random items left unattended. The garden table and chairs were dusty and covered with cobwebs. We shared this with the deputy manager and the garden areas were cleared.The weather was good on both days of the visit. We sat in the garden with a few people having some conversations. However, staff did not ensure they used those areas regularly to engage with people including when they needed more emotional support.One person was using a mobility aid (to support their walking) that was last checked in August 2023, but it was not clear if required checks were caried out according to the manufacturer.This did not demonstrate the current systems and processes in place were effective at detecting and monitoring potential risks to people related to environment. The management team did not ensure they had effective oversight of the care environment to manage and monitor people’s safety.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.The provider did not ensure they organised their staff effectively to ensure people received their commissioned hours and appropriate support according to their wishes and preferences. We often observed people were asked to go to their rooms without a reason. Although people went out for a walk, there was no further meaningful engagement between staff and people.Plans of care also described to involve people in daily tasks to reduce the risk of them becoming upset but also it was something that some people liked. However, we did not observe this was happening. People who had to have one-to-one hours of support, were spending time alone.When people became upset or distressed, staff did not always have effective skills and knowledge to support them in meaningful and caring way.

Daily notes did not describe clearly that staff used effective techniques to support people at those stressful times and that they followed required plans of care to support people’s emotional wellbeing. For example, we observed one person became distressed and came down to the communal area, however there was not much engagement and thus they became upset; the staff eventually gave the person biscuits and took them upstairs. Person’s care plan had detailed information about 3 levels of distress they would experience, how they would present at each level, and how staff could respond at each level to support and minimise their distress. The staff did not respond and support this person to minimise their discomfort or distress before it heightened. Staff did not communicate effectively in the moment; such as using Makaton or engagement with activities. Staff did not always demonstrate they could recognise people’s levels of distress and use guidance from care plans to support people whilst ensuring the risk of harm and abuse was mitigated.

The training matrix showed some staff had to complete different topics related to support for people with specific needs. However, our observations during the site visit demonstrated none of the staff acquired skills and knowledge from these training sessions. This indicated improvements were needed to ensure more positive and confident communication between people and the staff team. The provider could not assure us they had good oversight of all the staff and their competencies to be able to support and respond to people and to ensure they understood their different needs. This put people at risk of being cared for incorrectly or not according to their needs or conditions they may have or achieve good outcomes.

The provider did not always ensure all required recruitment checks and information were gathered before staff started work. We found missing information such as evidence of conduct from a previous employment working in health and social care. Records did not always include information of the verified reasons why the previous employments ended. We found the provider did not always ensure Disclosure and Barring Service (DBS) checks were carried out before staff started working at the service. For one staff, part of the risk assessment was not to work alone and to be under supervision from other staff. But we observed the staff supported people on their own. This risk assessment was also completed after our site visit. By failing to obtain all required recruitment information, the provider put people at risk of being supported by unsuitable staff.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading. People were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic. Staff used personal protective equipment (PPE) when required to keep the service clean and tidy. The service followed the guidance about visiting; there were no restrictions to relatives and friends visiting people.Relatives agreed the home was kept clean and tidy.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.People had prescribed medicine and also homely remedies to be used. However, the homely remedies were not always noted on the medication administration record (MAR) sheets so staff could sign it once administered. For example, one person had an antiseptic cream, but it was not clear how to use it and where to sign it. Some homely remedies had varied doses, but the information lacked details how staff should manage such medicine when people needed it or if it was needed at all. One person also had 2 types of medicine for pain relief but only 1 was noted on the MAR sheet. Another person had ‘when required’ (PRN) medicine prescribed to aid sleeping if needed. But it was also noted on the ‘homely remedy’ list and was administered. It was not clear from daily notes why it was given to the person. The person also had PRN inhaler but the protocol and MAR sheet information regarding dosage did not match. When PRN medicine was given, staff did not always record the details such as rationale on the back of the MAR sheet.

We reviewed people’s medicine and care records and noted they had PRN medicine prescribed to support with emotional wellbeing. However, this was only to be used as the last option to ensure it was the least restrictive method. People’s daily notes did not assure us that medicines for distress were being used appropriately. For example, one person presented upset and staff tried to console them. Daily note entry stated, “Staff comforted [them] by telling [them] that it is ok but still [they] didn’t listen so staff give [them] PRN”. This did not evidence staff tried alternative techniques such as re-direction, offering a drink or engaging in an activity. PRN medicine was administered to this person without evidence this was the least restrictive option available.Another person did not want to have a shower, so the staff gave them PRN medicine. However, this did not demonstrate the staff made any attempts to work with the person or ask them to have a shower at a later time in the day.When people had to have medicine to support them with their emotional wellbeing, the records on the back of MAR sheets were not always legible to understand the rationale for administration. PRN protocols did not always include clear details when to administer medicine which would ensure it was used as the last resort.One person was prescribed sedatives as and when needed, however MAR sheet information, guidelines and PRN protocol did not have accurate information. The person had one medicine stopped in January 2025 however the medicine has not been disposed of and the protocol was still in place.