Seaford Family Care

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 is the first assessment for this newly registered service. This key question has been rated 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 of the service.

This included lack of oversight of care plans, risk assessments and learning lessons. Also, staff opportunities to speak up.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager 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. There was a negative culture at the home and staff told us they felt unsupported by the registered manager and had few opportunities to speak up. The registered manager who was also the provider was responsible for 3 services based at 2 separate locations and split their time across the 2 sites. A service or deputy manager was in place and the future plan was to have separate registered managers for each of the 3 services. The registered manager told us their vision for the future was to continue to provide a homely environment for people to live in and to create a staffing structure that supported this. At the current time it was challenging for the registered manager to maintain oversight of all 3 services and this was apparent with some staff telling us that they rarely saw the registered manager at the home. A more robust management structure was needed to maintain oversight and to drive improvements to the service. Contingency plans were in place and a process to support people to move to the sister home in the event of a major incident.

The registered manager did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.Feedback relating to how the service was run was not positive. The registered manager told us that the service was able to run itself without them being there all the time, however this view was not shared by other staff. The registered manager said that they were confident that staff would come to them if there was a problem, but it was not clear how a problem would be identified by staff. A staff member said, “The (Registered) manager appears not to care. It’s like we do not have a manager.” There was an out of hours on-call process for staff to contact either the registered manager or deputy manager if support or advice were needed in their absence. Staff told us that the registered manager rarely answered their phone and, on most occasions, they had to then call the deputy manager. Other comments from staff included, “The service had declined over the past 2 years especially in the past 2 months but I’m not quite sure why,” “They (managers) lock themselves in the central office” and “(registered manager) is there maybe 1 day a week.”. Another concern related to staff training with staff telling us there was an expectation that online training was completed in their own time and at their own expense. The registered manager told us they found it challenging to get the staff to complete their training.

Staff did not feel they could speak up and that their voice would be heard. Although there were some processes in place for team meetings and providing staff with an opportunity to speak up these were inconsistent and staff told us they did not have confidence in the process. The registered manager told us that team meetings were held every 3 months but that it was difficult to get everyone there. Minutes from meetings however showed only 2 staff team meetings had been held in the past 18 months. The registered manager acknowledged that staff morale had declined and believed this was due to a perceived uneven distribution of work. The last staff meeting was held in July 2025 and one before that, November 2024. The minutes from the July meeting were brief, did not contain a list of attendees, had no record of staff voice or an exact date of the meeting. There were no actions but some agreed next steps one of which was to ‘collect staff feedback on meeting structure and topics for future agendas.’ We were unable to find any feedback on this point. Staff told us they were not confident to speak up at meetings, one said, “(Registered manager) has shouted people down in team meetings when issues are raised. Now staff scared to raise concerns.”

The registered manager did not always value diversity in their workforce. They did not always worktowards an inclusive and fair culture by improving equality and equity for people who worked forthem. Not everyone who worked at the home felt comfortable and fully supported. However, these concerns were not related to diversity or people’s differences but staff told us the culture at the home was not welcoming and inclusive. The registered manager told us they welcomed all staff with different experiences and that different people brought different qualifications, skills and life experience to the home. However, the ongoing support for staff and the approachability of the registered manager had led to some staff feeling isolated and excluded. Staff told us that diversity and equality were not an issue with one saying, “I like to work with different people and different cultures. That is good here.” Most staff had received equality and diversity training.

The registered manager did not have clear responsibilities, roles, systems of accountability and goodgovernance. They did not act on the best information about risk, performance and outcomes, orshare this securely with others when appropriate. Auditing processes were not effective. There were some auditing processes in place for example, accidents and incidents, training and medicines. These processes however had failed to identify themes and trends. There was no evidence of interview questions to show appropriate knowledge relevant to role from the notes of initial staff interviews. The training matrix showed some gaps in every training module showing that not all staff had completed the required training. Some medicine administration records were missing and there were very few recommendations made following reviews of accidents and incidents. Auditing processes had failed to identify these issues and limited action had been taken to address issues that had been identified. Care plans and risk assessments had not been reviewed or audited for over 12 months. Only recently had an additional staff member been employed, part time, to carry out these reviews. This remained a work in progress and several documents were still waiting a review at the time of our assessment. The registered manager acknowledged their responsibility for the auditing processes but a more effective and regular system for all areas were needed to enable both positive and negative trends to be identified and addressed. Feedback from the MOCH team confirmed the home had not made full use of the services they offered and that they had highlighted a potential issue with data security relating to the use and sharing of the secure NHS email system within the home.

The registered manager did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement. Feedback from professionals that regularly visited the service was mixed. Some professionals told us there had been little improvement in communications with the service during the last 12 months with suggestions, offers of help and training, not taken up. It was unclear why these offers had been declined but there remained areas of the service that required improvement to benefit the service being provided to people. Relatives told us that although day to day appointments and working with other professionals to achieve this was not a concern, there were longer term issues that could be improved for example, communication and providing a safe environment. The latter referred to people’s free access to the home kitchen. Others however reported no concerns. A professional said, “Based on my involvement with the service, I have no concerns to raise. Pathways and transitions appear to be managed appropriately.”

The registered manager did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. The registered manager told us they did not have time to attend any registered manager forums or undertake any ongoing improvement for the home themselves. They said that the transfer of the service to them in November 2023 had been challenging and taken a lot of time. Learning from both positive and negative incidents and events that had taken place at the home had not always been shared with staff. Consequently, there was no indication of continuous improvement embedded at the home. Improvements had been made to the décor of the service and a staff member had been employed to specifically review care plans, albeit only in the past few months.