Seaview Haven

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, premises and equipment and staffing.

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. Lessons were not learnt to continually identify and embed good practice.

We observed poor moving and handling practices which placed people at risk of injury. In 1 instance, a person who required staff support to transfer was not correctly positioned on the transfer equipment. This improper technique not only compromised the safety of the person but also increased the likelihood of physical harm, discomfort, and distress. One relative told us: “The staff tried to get them up without the brakes being on the equipment”.

A further example, inspectors identified an inconsistency within one person’s care plan regarding choking risk. The care plan assessed the person as being at high risk of choking, yet in the same document, it was stated the person did not require assistance with eating and showed no signs of swallowing difficulties or choking. The conflicting information within the care documentation posed a risk to the person’s safety, particularly during mealtimes when choking hazards are most acute as staff did not have clear information and guidance on how to support this person with how to eat safely.

The provider had not demonstrated learning from a previous serious choking incident involving this person.

Systems and processes in place were insufficient to identify and address discrepancies in care documentation, and lessons were not consistently embedded to promote good practice. We could not be assured lessons were being learnt to keep people safe.

The manager worked well with people and healthcare partners to establish safe systems of care, but these were not always maintained. They did not always manage or monitor people’s safety. Summaries of people’s needs were available for first responders if people had to be admitted to hospital unexpectedly. People were supported to stay with the same local GP if they wished to when they moved into the service. One relative told us: “The staff were calm and gentle with people, and if any health issues or anything needed following up such as calling the GP, it was done straightaway.”

However, care planning and risk assessment processes to maintain and monitor safe systems of care were not sufficient and not all care plans and risk assessments were up to date. For example, people's health needs were not clearly documented, and associated risks were not always considered. People's records lacked important information regarding their safety, health and wellbeing.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve this. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from avoidable harm and neglect.

Staff were trained in safeguarding with policies and procedures in place to support and guide staff in their practice. However, some staff told us they didn’t feel the management team listened or responded to concerns they had raised. For example, a staff member said they had reported a safeguard concern to the management team, but no investigation took place. We subsequently followed this up with the Local Authority to make sure people had been protected.

Closed-circuit television (CCTV) was used to monitor communal areas, in order to safeguard and protect residents and staff.

We checked whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found systems were in place to monitor legal authorisations and renewals were completed when required.

One person told us “I’ve got the other residents and staff here which makes me feel safe”.

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

Risks associated with choking had been assessed and reviewed for some people, but this was inconsistent. For example, we identified a person who had a recent hospital admission after choking, however their care plan had conflicting information which placed them at risk of future choking. For another person we found conflicting information in relation to modifications they required to their diet to mitigate the risk of them choking.

However, kitchen staff were receiving further training regarding food consistencies in line with Speech and Language Team [SALT] guidance and additional training with meal preparation and presentation. The provider also told us Dysphagia training had been arranged and moulds for pureed foods had been purchased to improve the presentation of meals and encourage people to eat.

Key risks relating to areas such as falls, nutrition and skin integrity had been reviewed and well managed for some people, but this was not consistent. For example, care plans, risk assessments and updates from health professionals were all in place for one person whose nutritional needs had been assessed as being a cause for concern. However, the care plan for another person at risk of weight loss contained contradictory information and staff did not always follow the detail of the care plan. Weight management records were incomplete for this person.

Care plans to support people’s skin integrity were not always up to date and reflective of their needs, this posed a risk that staff would not know how to support the person safely.

A medical professional told us: “The team are managing him very well by involving him with purposeful and meaningful engagement which reflects best practice. Subsequently this is reducing the risks in the least restrictive option”.

We saw staff remind people to use their walking aids, as per their care plans, to promote safe mobilisation.

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.

Systems were in place to make sure regular safety and maintenance checks were completed and systems for fire safety were in place. Refurbishment of the home environment and communal areas was ongoing, and maintenance staff used their initiative to identify and prioritise this work. However, during inspection we reviewed the kitchens cleaning records and facilities. We found multiple cleaning records had not been completed and there were areas of the kitchens that were visibly dirty. A lack of cleanliness in food preparation areas poses hygiene risks and is not compliant with expected food safety standards.Following our visit the provider told us they had commissioned an external contractor to complete a deep clean of the kitchen.

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 work together well to provide safe care that met people’s individual needs.

The provider informed us a dependency tool was used to support workforce planning and ensure sufficient numbers of skilled staff were on shift to meet the needs of people using the service.

However, staff told us there was not enough staff to support people's needs. Comments included, "Staffing is not great we are really busy all the time". Some staff expressed frustrations regarding staff morale and lack of support they received from the management team.

Inspectors reviewed supervision records and found 10 staff members were overdue for supervision and when they did occur, they were described as brief and task-focused rather than supportive or developmental. Several staff said supervision felt more like a “telling off” than a constructive conversation. People told us care tasks often appeared to be rushed because the staff were busy.

One relative told us: “At weekends when we visit the reception is not manned, but there is a number to call if no one responds to the buzzer. We have had to stand outside for 5-10 minutes waiting before being let into the building”.

Staff had been recruited following the provider’s recruitment policy and security checks had been made on staff members.

People and relatives told us staff were trained to support them safely with their care needs. Staff explained their training induction into the service when they first started working there. One staff member told us, “We had to go through policies, learn how things are done in the home”.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading.

The service had an up-to-date infection prevention and control (IPC) policy, and routine IPC audits had been completed, with documentation indicating compliance with the provider’s IPC procedures. One relative told us: “Whenever we walk in there’s always an odour, neither pleasant nor unpleasant”.

Cleaning schedules for the home environment were also in place, reflecting a planned approach to maintaining hygiene standards. One person told us: “The toilets are clean and there are no smells in the building”.

However, staff did not always wear personal protective equipment (PPE) appropriately during mealtimes, and there were multiple and widespread shortfalls in the implementation of safe IPC practices in the kitchen. For example, inspectors observed kitchen hand washing sinks were filled up with dirty crockery, limiting the ability of staff using the service to maintain effective hand hygiene. We identified several concerns regarding food safety practices. Specifically, we found out-of-date items stored in fridges, as well as fresh food that had been opened but was neither labelled with dates nor adequately covered. These practices posed a risk to people, potentially leading to cross contamination, foodborne illness and undermining efforts to maintain a safe and hygienic environment.

Additionally, observations of the kitchen environment made during the inspection did not align with the records reviewed, indicating gaps between documented procedures and actual practice. Despite kitchen cleaning schedules being in place, these were not consistently completed. We found the kitchen environment to be visibly unclean with the overall standard of cleanliness in the kitchen poor and failing to uphold basic standards of hygiene.

Some improvements were noted on the second day of the inspection, such as the hand washing facilities in the kitchen were available to be used. Following our visit, the provider told us they had appointed a new kitchen manager.

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.

For example, we found a medicine room and the medicine trolly had been left unlocked and unattended by staff. We raised these concerns with the provider, and they took immediate action to secure the medicine room and medicine trolley. There was no harm caused to people.

We saw staff, where appropriate, had received medicine training and had their competencies assessed by the manager. People’s medicine had been administered in accordance with their needs and had been recorded appropriately on people’s medicine administration records (MARs).

There were protocols in place for medicines required ‘as and when’. We saw discussions had taken place with healthcare professionals, for example, the GP and pharmacist. One relative told us: “The home are very good at getting in touch with us immediately if there is a medical issue for mum”.

Where the person lacked the mental capacity to understand the importance of taking their medicines, decisions had been made following the best interest process, in line with the Mental Capacity Act 2005 and recorded accordingly. One nurse told us: “Communication and consistency between the provider and health professionals has improved in the home over the past few months”.