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Inspection carried out on 3 September 2020

During an inspection looking at part of the service

About the service

Seaview Haven is a care home providing accommodation for up to 44 older people, including those living with dementia. At the time of our inspection, there were 38 people living at the home, with one person in hospital.

People’s experience of using this service and what we found

There was a calm and organised atmosphere when we visited. People were happy and comfortable. There were good interactions between people and the staff who supported them.

Risks to people’s safety had not always assessed, monitored and recorded. This related to the management of people’s pressure sores and the use of a specific type of chair which restricts a person’s mobility. The management team were open, honest and transparent in relation to these safety incidents. They had taken action to find out what went wrong and learn from this. One incident of a person with a serious pressure sore is currently being investigated by the local authority safeguarding team at the time of this report.

Communication issues had been identified by health and social care professionals not being able to get in touch with the home by telephone. As a result, the home had increased the use of more telephone lines and mobile phones.

Further improvements were also identified by both professionals and the management at the home to improve their partnership working to ensure positive outcomes for people. This would ensure health information is passed over quickly between both parties as soon as possible. This is work in progress with some changes already made.

The registered manager was aware of their role, was visible and had an oversight of the service. They were supported by other senior staff with delegated responsibilities. When required, they worked with the local safeguarding team to provide information.

People were supported by adequate numbers of staff on duty to fully meet their needs. Staff had picked up extra shifts and agency staff were used when necessary. People told us there needs were met in a timely way. The management team were in the process of recruiting more staff to supplement and increase the staff team.

People were protected by living in a home which had suitable arrangements in place for the prevention and control of inspection.

Rating at last inspection

The last rating for this service was good (published July 2019).

Why we inspected

We undertook the targeted inspection to check on specific concerns we had which related to the safe care and treatment of people, specifically the numbers of staff on duty, communication issues, the numbers of people with a pressure sore and the oversight of the service.

CQC have introduced targeted inspections to follow up on a Warning Notice or other specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We found the provider needs to make improvements in some areas. The provider had already taken action to mitigate the risks to prevent a reoccurrence


We made two recommendations to improve practice in relation to pressure sores and partnership working.

Please see the safe and well led sections of this full report.

You can read the report from out last comprehensive inspection, by selecting the ‘all reports’ link for Seaview Haven on our website at

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 22 May 2019

During a routine inspection

About the service: Seaview Haven is a ‘care home’ for a maximum of 33 people. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection there were 29 people living at the home, of which three people were currently in hospital.

People’s experience of using this service:

At our previous inspection in September 2018 there was a lack of robust quality monitoring systems in place to ensure the quality and safety of the service and record keeping was not comprehensive. This inspection found improvements had been made.

At our previous inspection in September 2018, people did not have risks assessed relating to their health, safety and welfare and people were not receiving their medicines in a safe way. This inspection found improvements had been made. Robust risk assessments were now in place. People’s individual risks were identified, and the necessary risk assessment reviews were carried out to keep people safe. For example, risk assessments for moving and handling, falls and skin care. Medicines were now safely managed on people’s behalf.

Prior to this inspection, we had received information about staffing levels being inadequate to meet people’s needs in a timely way. This information was not substantiated, although it was clear there had been issues with staffing levels up until approximately two months previously.

The service provided safe care to people. One person commented: “I feel 100% safe, they look after everyone with kindness.”

Care plans for people had now been brought up to date and detailed people’s individual needs, wishes and choices. People’s views and suggestions were taken into account to improve the service. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff relationships with people were caring and supportive. Staff provided care that was kind and compassionate.

Most people informed us that they were not keen on some of the food that was served. We raised this with the manager, who agreed to look into further training for the cooks to improve the foods on offer.

There were effective staff recruitment and selection processes in place. People received effective care and support from staff who were trained and competent. Until February 2019, staff had not been receiving on-going supervisions in order for them to feel supported in their roles and to identify any future professional development opportunities. The new manager ensured this was remedied and now all staff were receiving this level of support.

Rating at last inspection: Requires improvement (report published in October 2018).

Why we inspected: The inspection was prompted in part due to both the Care Quality Commission and local authority receiving information of concern about the timeliness of people’s care and treatment; pressure area care; staffing levels and training and the general leadership and management of the service. This inspection found that the concerns were not substantiated. Following our inspection, we spoke with various health and social care professionals as part of a safeguarding meeting. At this meeting it was agreed that the service did not meet the threshold for a whole home safeguarding process. This was because we were all assured that the service was working hard to improve the overall leadership and management of Seaview Haven.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at

Inspection carried out on 5 September 2018

During a routine inspection

This unannounced comprehensive inspection took place on 5, 12 and 14 September 2018.

Seaview Haven is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Seaview Haven is a care home which previously belonged to the local authority. It has undergone an extensive refurbishment and provides a high standard of fixtures and fittings. This was the provider’s first inspection.

The service was registered for 29 people. There were 27 people living at the home at the time of inspection, many of whom were living with dementia. Seaview Haven is a care home situated in a residential area of Ilfracombe. It has accommodation sited over three floors, some rooms with extensive sea views. However, at the time of inspection the upper floor was not in use, except for one person who had chosen to live on that floor.

The service had a manager who had registered with the Care Quality Commission (CQC) in July 2018. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was supported by the nominated individual and the deputy manager who formed the management team. They had worked together for the previous four months.

The service had been registered with the CQC since October 2017. In that time, two other previous managers had led the service. However, both had left within a short space of time and had not been registered with CQC. This effectively meant that since the service was registered, it had operated without a stable registered manager in place until recently.

Despite the management team working closing together, there was a definite lack of leadership and oversight of the whole service. This was due in part because the management team had previously managed services with a different type of service user group with a different type of need.

People’s health, safety and welfare were put at risk because there were many risks to the environment, both inside and outside of the building. People’s individual risks had not always been assessed and managed in a safe way. There was a lack of quality monitoring and inconsistency in record keeping.

Because of the seriousness of the concerns found on the first day of inspection, we wrote to the provider and management team setting out our concerns. They recognised and acknowledged the concerns raised. They were upset and disappointed at the findings but agreed with the judgements. They recognised action was required and put together an action plan with timescales for action. They confirmed their commitment to addressing all concerns and their assurances to improve the safety of people living at the service. On the second and third day of inspection, all the concerns had a plan to put them right. Some of the work had already been completed and some areas made safe whilst a permanent fix was made. Health and social care professionals had been contacted and arrangements for assessments to be made.

People were not protected from unsafe and unsuitable premises. The provider’s quality assurance systems did not take place regularly and had therefore not picked up the deficits and shortfalls identified during the inspection. The provider had not completed an environmental risk assessment or monitoring checks to ensure the environment was safe. In particular, we highlighted risks due to open access to unsafe areas both inside and outside of the building. No monitoring checks had been undertaken in relation to bedrails and beds to ensure they were safe and at the correct settings for the individual person.