Seaview Nursing 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 Requires Improvement. At this assessment the rating has remained 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.

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 had not always worked well with people and healthcare partners to establish and maintain safe systems of care. They had not always managed or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People did not always have hospital passports in place when required. These documents support people when they move between services such as admission to hospital. They contain important information such as people's individual communication needs. This placed people at risk of harm of not having their needs met. Feedback from two health professionals said that specific essential information regarding one person had not been readily available and when produced had been incorrect. We were also told that emails and telephone calls regarding people’s health concerns were not responded to in a timely way. It was acknowledged that this had improved recently with changes to the management team and the introduction of an interim deputy manager. However, over the past two weeks this improvement had declined again as the deputy manager had returned to their original place of work. A new deputy manager who will also be the clinical lead had been employed and started their role during the assessment process. This will help embed good practices.

The provider had not always worked well with people and healthcare partners to establish and maintain safe systems of care. They had not always managed or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People did not always have hospital passports in place when required. These documents support people when they move between services such as admission to hospital. They contain important information such as people's individual communication needs. This placed people at risk of harm of not having their needs met. Feedback from two health professionals said that specific essential information regarding one person had not been readily available and when produced had been incorrect. We were also told that emails and telephone calls regarding people’s health concerns were not responded to in a timely way. It was acknowledged that this had improved recently with changes to the management team and the introduction of an interim deputy manager. However, over the past two weeks this improvement had declined again as the deputy manager had returned to their original place of work. A new deputy manager who will also be the clinical lead had been employed and started their role during the assessment process. This will help embed good practices.

People told us they felt safe.Comments from people included, “Staff are lovely, they look after me well,” “I like it here, I can count on the staff to look after me,” and “It’s nice, my room is my own and I have all my bits around me.” One person said, “I do get bored, but it’s not anyone’s fault, the food is very good, and we get lots of choices.”

The provider had not always worked well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They had not always concentrated 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 had not always share concerns quickly and appropriately.

Information gathered from health professionals, social care and from families indicated that not all incidents and accidents were reported to the relevant authorities in a timely way. For example, skin tears, self-neglect and medicine errors and falls.

However, there were a large number of outstanding safeguards in the early part of the year that have now been resolved under the new management team. We viewed the action plans provided by the provider.

There were organisational procedures for safeguarding people. These provided guidance about the action to take if staff had concerns about the welfare of people. Training records showed staff had completed safeguarding training. There was a system in place for recording safeguarding concerns which management have oversight of.

Our observations found that people were comfortable with staff, we saw positive interactions, which assured us they felt safe and comfortable. People and their relatives told us that Seaview was safe. One person said, “I do feel safe here, staff are kind and patient, never raise their voices.” Relatives' comments included, “I know who to go to if I have a problem.”

Staff were aware of the signs of abuse and how to report safeguarding concerns. Staff confirmed that they had read the policies as part of their induction and refreshed at yearly safeguarding training. They were confident the management team would address any concerns regarding people’s safety and well-being and make the required referrals to the local authority. Staff had a good knowledge of whistleblowing procedures and would use them if they felt their concerns had been ignored.

One staff member said," We all have to do training, it’s very in depth.” Another said, "We have a policy to follow, and I would inform the manager, or the nurse and record on our system."

People were supported by staff who knew them well. Staff supported people with kindness, respect and followed good practice guidance when assisting them. Staff were mindful of people's characteristics and promoted their dignity, people were dressed in their own clothes. Staff introduced us to people and were knowledgeable about them. People were observed to approach or call staff for assistance and staff responded in a kind and respectful manner. The mealtime experience had improved and was now more inclusive, and we saw that people sat in friendship groups.

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. The Act requires that, as far as possible, people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. 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). Staff received training in the principles of the MCA and understood their role and responsibility in upholding those principles. The manager kept an overview of all DoLS applications and those that were completed, pending and those that were refused. Individual care plans and risk assessments reflected these restrictions and the reasons for the restrictions.

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

Care plans and related risk assessments were not all person-centred or reflective of people’s individual needs. Care plans and risk assessments were not always updated to reflect changes to their health and well-being. Reviews of care needs were not always meaningful and lacked depth regarding changes to people’s needs.

Where people lived with a mental health diagnosis there was a lack of direction for staff of how to manage mental health changes. For example, care plans did not include up to date guidance for staff about triggers and de-escalation techniques for staff to use to help re-assure the person, and there was no guidance written in respect of the one-to-one role of staff for positive engagement in daytime hours. For those at risk from self-neglect, there was minimal reflection of how this impacted on the person and no mention of tried strategies to manage this safely.

Care plans for people who lived with specific care and support needs were not all accurate and this had the potential to impact on safe care delivery. For example, nutritional guidance, safe positioning and wound care. Some body maps showed injuries but there was no corresponding accident form or care plan in place.

Discrepancies with the care plans and risk assessments were fully discussed with the manager and area manager. The area manager had identified shortfalls in care documents since being in post and was holding teaching sessions to improve staff approach to care planning and using the computerised system effectively. Seaview Nursing Home was being supported by the local authority regarding documentation. The management team acknowledged that there was work to do and had submitted an action plan to address the issues. Staff we spoke with had an understanding of peoples care and support needs, which reduced risk to people, but agency staff and newly recruited staff would not have that knowledge. To further mitigate risk, there was a ‘flash’ meeting every morning with all departments, to identify risks, such as who was on nutritional and fluid watch, new admissions, GP requests, falls and any other service news. We saw evidence of this.

There were some positives noted from the last inspection, which included a decrease in falls and incidents since February 2025, the incidence of home acquired pressure wounds has also decreased. Wound care documentation had improved, although this needed to be fully implemented and embedded into daily practice.

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 observed some parts of the home were still in need of repair and redecoration. There is a plan in place, but progress has been slow. We were assured by the area manager that these would be a priority going forward. People’s rooms were not all personalised, well decorated and comfortable and some flooring needed to be replaced as it was torn, we were assured that the maintenance team had been informed, and this would be progressed immediately. The action plans for the environment were fully discussed during the assessment.

Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, moving and handling equipment, staff safety and welfare. There was a business continuity plan which instructed staff on what to do in the event of the service not being able to function normally, such as a loss of power or evacuation of the property. Premises risk assessments and health and safety assessments were reviewed on an annual basis, which included gas, electrical safety, legionella and fire equipment.

The provider did not always make sure there were enough qualified, skilled and experienced staff to provide safe care that met people’s individual needs.

Feedback about staffing from people, relatives and staff was mixed. Some people told us there were enough staff to provide safe care, whilst others said more staff would be beneficial. One person said, “Never had to wait for a staff when I need assistance, they are very good,” and “The staff are good, reliable and kind. A relative said, “There is always someone to greet us when we visit but it can be difficult on the unit to find staff member but there is always someone in the dining room,” and “I think staff seem rushed sometimes but that’s no disrespect to staff, there needs to be more activity staff, that would help I think.”

The layout of the building meant that there were areas of the home that were isolated, and we noted that staff were not visible in these areas when providing care. For example, three people were sat in the cinema room and there was no staff oversight. Each time we visited the 3 people were dozing. We brought this to the attention of interim manager as there was no call bell facility in easy access for people. This was immediately dealt with, and we were told of the reasons why this had occurred. The area manager has provided walkie talkies so staff can be found immediately if required. The area manager has confirmed that they were pro-actively looking at staff deployment and numbers of staff based on people’s needs and the lay-out of the home.

Staff recruitment was on-going, and they had successfully recruited a clinical lead, registered nurses and care staff. Recruitment was on-going for activity staff as one had recently left.

Improvements were needed to ensure safe recruitment systems were followed as not all files seen had the necessary information included, such as gaps in employment history, interview notes and current addresses. We received confirmation that these had now been found and added.

The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least two references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people. Registered nurses have a unique registration code called a PIN. This tells the provider that they are fit to practice as nurses. Before employment, checks were made to ensure the PIN was current with no restrictions.

Agency staff were used and there were checks completed by the agency and supplied to the management team at Seaview Nursing Home to ensure they were safe to work at the home.

The provider did not always assess or manage the risk of infection or manage offensive odours in the premises.

There were strong odours throughout the home which were unpleasant. These were identified to the management team and staff during the first site visit. On the second and third site visits the odours were decreased and being managed more effectively by the housekeeping staff.

We were also told that a deep clean was being arranged to assist the housekeepers as there was an issue with the carpet cleaners and any carpets that required replacing would be replaced. It was also acknowledged that areas of poor décor and floor coverings made it difficult to clean and manage lingering odours. Actions to be taken forward were included in the programme of improvement from the area manager.

We saw housekeeping staff undertaking cleaning in all parts of the home. Our observation of the environment raised some concerns regarding procedures in place for cleanliness, such as floor cleaning, these were fully discussed and taken forward by the head housekeeper to seek advice from the Health and Safety Executive. We were also aware that some odours were unpreventable, but clear management of these needs to recorded and monitored.

People’s laundry was managed well, and the laundry room was clean and well organised, and people were well dressed.

All staff understood their responsibility to reduce the risk of infection and followed infection control guidance. There were posters and training to assist staff in keeping up to date with any changes to infection control measures. Audits were completed by the infection control lead to ensure compliance with the procedures and policies of the home. Staff were trained in the use of personal protective equipment (PPE) and of the importance of good hygiene practice.

The provider had not always made sure that medicines and treatments were safe and met people’s needs. Staff however involved people in planning, including when changes happened.

Not everyone could share their experiences regarding medication, but one person said, “I haven’t been here long, but I get all my medicines, but for health reasons, I can’t manage my medicines anymore, but the staff discuss them with me and the doctor reviews them with me.” One family member we spoke with said, “Staff always tell us of changes, especially if the GP changes the medication, I have no concerns.”

There have been a number of concerns raised regarding medicine management, and these were being looked at under a current safeguarding investigation with the support from the Medicines Optimisation for Care Homes (MOCH).

Protocols for 'as required' (PRN) medicines such as pain relief medicines were in place however, they were generic and lacked personalisation. Pain charts were not consistently used and outcomes for the action of pain relievers and medicines to relieve anxiety disorders, whether it had a positive effect or not, were not recorded. This meant the effectiveness of PRN medicines could not be monitored. Not all handwritten entries into the medicine administration records (MAR) were signed and dated by two staff as the medication policy states. One covert (medicine hidden) medicine chart was found in the MAR folder, but all details were from the previous service and had been completed in 2023. We were re-assured that the person was not receiving medicines in a covert way. This was removed from the folder.

Staff who gave medicines had the relevant knowledge, training and competency that ensured medicines were handled safely. We observed staff giving medicines safely and that they were recorded accurately. Risk assessments were in place for certain medicines. All discrepancies and medicine errors were now recorded and investigated and action taken as required. Daily and monthly audits were carried out, and any shortfalls were addressed.