Archived: Seabank 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

The service was not safe. The provider could not evidence systems in place to identify, manage and mitigate risks within the service and to people using the service. Records were not maintained showing the service was managed safely. This included records to show the service had quality of care auditing processes, staff training and development records, supervision, appraisal and competency assessments, DoLS authorisations, health and safety audits, equipment servicing and an internal and external environmental risk assessment of the service, a maintenance and upgrade plan.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We observed people moving freely and independently around the home including the outside areas where support was not required. We observed people using the kitchen independently to make refreshments and tasks to undertake such as their own bedroom cleaning, hoovering, taking milk bottles out for the milkman and washing dishes. We observed people using equipment in the service. One person told us, 'I like to do jobs, I like helping'.

The registered manager could not evidence that there a formal process to obtain the views and feedback of the people, their family members or partners including commissioners and health professionals who are involved with the people residing at Seabank House. Concerns about safety were not formally recorded, we were not assured that safety events were investigated and reported thoroughly, and lessons were not learned or shared to continually identify and embed good practices, This was evident from the discussions held, including feedback provided to the registered manager at the time of on-site activity identifying areas of concern and where improvements were required. We fed back observations made in relation to unsafe moving and handling practice on day one on site activity, these were not acted upon appropriately to learn from poor practice.

The provider did not have the processes to ensure there was a learning culture. We shared our concerns regarding the first floor fire escape and route, this was reported and fed back to the registered manager on day one of on-site assessment, there was no improvement by the third day on-site visit, no lessons learned by the provider, or action taken to rectify, due to this inaction we made a referral to the Merseyside Fire Service regarding our concerns of the inaccessibility of the escape route and the slippery state of the luminescent strips on the steps that had worn away. From the information observed in the accident recording book there is no formal process of action taken, improvements to consider or lessons to be learned shared with the staff team regarding accidents and incidents, this was observed for the staff and peoples entries in the book. Seabank House had a quality and safety assessment from the Local Authority 28 November 2023 and a formal action plan to follow for improvements, we corroborated from our on-site assessment that the same issues and concerns and areas for improvement were still present, seemingly lessons had not been learnt, actions were not completed regarding safety concerns with the absence of remedial action taken. We did not observe risk assessments for people to coincide with the activities undertaken and equipment used in the home, this also included environmental risk assessing internally and externally. We observed a persons care plan and risk assessment which does not show a full review, lessons learned, practice to share with staff following a recent incident of self-harm that required hospitalisation and a procedure, we were made aware of this incident verbally while asking the registered manager questions, there was no further evidence in the persons care plan to identify that this incident had occurred.

We observed that people have resided at Seabank House for several years and the last transition into the service was over 5 years ago.

Discussion with the registered manager evidenced that there is not a formal process to evaluate, obtain and maintain safe systems of care, we were not assured by our on-site assessment activity that safety in relation to safe systems of care, this was not managed and monitored, this included the observations we made which will be reflected fully in this report.

Partners told us they were concerned about the service and some had taken action to mitigate the risks presented. Our assessment was prompted by concerns raised by the local authority. The local authority had suspended the service, preventing further admissions. Partners had offered support to the service although this had been declined.

From the care plans observed we were not assured that people’s care and treatment was effectively being assessing and reviewing their health, care, well-being and communication needs with them was not being undertaken regularly. A care plan for one person we observed did not reflect the daily district nurse support that is provided for two separate health concerns, diabetes and pressure wound care. This does not support continuity of care from the district Nurse support and what the staff are required to support at home to promote good health and well-being.

We asked a person, 'do you like the staff here?' they answered 'Yes, and (person’s name) is home', they were asked 'if you were not happy with something would you speak to someone?' they replied 'Yes' and pointed to the registered manager while they said this.

In interview the registered manager did not demonstrate a strong awareness of safeguarding practices or recent safeguarding cases. Members of staff were aware of recent safeguarding referrals which had not been investigated or responded to appropriately by the registered manager.

Outside hazards - a drop outside from upper level of garden to lower concrete floor, not made secure or fenced off appropriately, which was a falls risk, no risk assessment available for this area. Rubbish and equipment piled and stored at the back of the property. Fire escape issues - no clear route as it is blocked with overgrowth and debris, bags of debris and the luminescent strips on the stairs were slippery when wet. Downstairs fire exit by the kitchen had items blocking the escape route path on the outside. The back storage room, which was accessible, had toxic materials, tins of paint strewn on the floor, a collapsed ceiling which was next the kitchen which was accessible to the people residing there. A maintenance plan and upgrade plan was not available for the home – building integrity has been compromised in areas. The provider could not provide assurances on an asbestos survey given the concerns of the buildings state of visual disrepair. Black mould on ceiling found in main hall. Cat faeces found on the floor upstairs – service pet which free access to the kitchen as it is wedged open, cat litter tray was in the main hallway. We observed a broken glass pane window in the porch, we also observed a broken glass pane on the landing window, both were in reach of people, no remedial fix undertaken after day 1 on-site visit feedback to the provider. There was no ventilation available in the laundry room, this is causing damp in the laundry room where laundry was also drying on a ceiling airer. We found a pressure cushion to smell of urine – this person also had a pressure wound. Boxes and flat packs of furniture to be assembled stored at front door entrance and had been present at each on-site visit. We found archiving storage boxes and crates sat outside the registered manager’s office/medication room which were present on all on-site visits. More in-depth detail regarding some of the areas detailed above are held in the safe environment key question.

The provider did not have a log of the safeguarding referrals that were made by them to the local authority safeguarding team or on their behalf against the service. Statutory notifications were not being submitted as required to inform the Care Quality Commission of notifiable events and incidents, notifiable incidents that we discovered through care records and discussions with staff and the provider. The provider did not provide evidence that staff had the appropriate training and safeguards including the mental capacity act training and Deprivation of Liberty Safeguards (DoLS) training in place, evidence of these training courses and completion were requested and not provided. Care plans were not reflecting the care and support needs for people, care records contradicted each other, care records were printed emails in some instances, and the provider was not able to evidence appropriate associating risk assessments to mitigate risks to provide safe care and treatment in line with people’s health and care support needs. In some instances, peoples diagnosed conditions and support requirements did not have an appropriate support plan and associated risk assessment, this meant that staff would not know how to appropriately support people if they became unwell, for example there was the absence of a diabetes care plan, epilepsy protocols, pressure care and wound support plans from a current wound and no consideration for repositioning charts, absence of a nutrition care plan in line with food intolerance's, catheter care plans and dementia support plans were all absent. This put people at risk because staff did not have clear guidance to follow to provide care and support appropriately and safely. We observed peoples DoLS authorisations had expired and one person’s conditions on the DoLS authorisation were not being met, not described and identified in a separate care plan and the provider failed to action appropriately.

We asked people, do you feel safe here at Seabank? One person responded 'Yes'. We spoke to another person in the lounge after their breakfast, do you feel safe here at Seabank? they responded 'Yes’ and nodded their head. We observed some people being independent in and around the home.

The registered manager was asked to provide documentation to evidence risks had been identified, considered, and mitigated, these were not provided, when discussing managing risks with people in care plans and managing risks in an environment the manager did not have robust assessments in place, in some instances none at all. When the care plans were discussed with the registered manager and feedback was provided on how they are required to be improved, to also factor in appropriate care plans and associated risk assessments, the manager provided a new care plan template that was going to be introduced in the service. We were informed by a staff member on the first day of our on-site assessment that they had been tasked with updating the care plans and stating, 'information was going into it if it needed it or not'. When staff were asked regarding keeping people safe using wheelchairs and foot plates for one person, a staff member stated that the person does not wish to use the footplates and declines to use them.

We observed care provided which was not in accordance with the identified risks presented by service users. The footplate was not used correctly for one service user and although staff told us this was because the service user regularly declines to use the footplate, this was not recorded in their risk assessment. The absence of robust care planning and risk assessing, regularly reviewing the care and support with people highlighted that the provider negated working with people to manage risks as the risks were not identified and mitigated. On our second and third visit we observed the same person being supported by staff with their foot plates correctly in use on the wheelchair and they were wearing slippers.

The provider did not have effective systems to identify and manage risks. While on-site undertaking the assessment of the service, we asked the provider to demonstrate the process they have to mitigate risks, work with people and include them in the care planning and risk assessment process. What we observed was the lack of a governance process. There was no oversight of the mental capacity act and the principles were not put into practice such as capacity assessments considered and best interest decisions made and recorded to support where people do not have capacity to make decisions. There was no oversight of DoLS applications, when they were made and when they were due to expire, and conditions detailed in the authorisations were not being met. People, family members and staff and their views were not considered recorded for improvements to be made, there was no formal process to capture a wealth of feedback possible to drive improvements in the service. The provider could not evidence that the environment was considered, risk assessed and made safe, this also included the feedback the service had been provided as part of the Local Authority quality and safety assessment. Personalised risk assessments were not in place for people using the equipment in the service. We were unable to evidence that people participated or were involved in creating their care plan where possible and the care and support including regularly reviewing outcomes as this was not taking place. We were not assured there was enough staff on duty as per the rota to support extra activities outside of the home as well as support in the home. We observed a persons care plan and found that they can communicate with Makaton, a communication care and support plan was not available.

We were unable to gather some peoples thoughts and feedback on this particular subject, especially the use of the hoist, and a profiling bed and wheelchair for one person, the people we spoke to when they were asked if they felt safe in the service they indicated that they seemed to feel safe and liked living at Seabank House, we observed people coming and going freely in the service, three people we spoke to liked their bedrooms. We observed from the rota and the staff files that a number of staff had been with the service a while; a number of staff members had been there for over twenty years.

The registered manager was asked to provide information while in discussion to evidence their activity to detect and control potential risks in the care environment. The registered manager stated that they had completed actions in the action plan from the Local Authority quality and safety assessment and the Infection and Prevention and Control visits that they recently had. A staff member also stated that they had undertaken a lot of work to complete actions from the Local Authority assessment. We asked to see copies of these actions from the service before the assessment on site activity began, these were not provided. Discussions with the registered manager highlighted the checklists that had recently been introduced were not effective as there were gaps present with no evidence of action taken and staff were not completing them. The registered manager stated that they had spoken to all the staff regarding the new paperwork, and that monitoring was taking place on Sundays. The provider stated that they were renting the property and had problems getting hold of the landlord for the last 10 years to get repairs undertaken.

There was a disregard for a safe external environment by the provider. The gardens were unkempt, poorly maintained and presented risks to people residing at the service. The provider could not provide evidence of an environmental risk assessment for the garden areas. There were risks which had not been assessed and mitigated including risks of falls from heights. There were risks of falls from heights presented by a vertical drop from the garden to the driveway which was only partially mitigated by a rail which did not fully cover the drop. The steps to the garden were narrow and uneven. There were walls which were crumbling and poorly maintained. Garden furniture was dirty and poorly maintained. The first-floor fire escape door was not alarmed, there was an unclear exit and route in the event of an emergency, the path to the gate was overgrown and inaccessible and the grey step markers were slippery underfoot. On our first day on-site we highlighted the concerns regarding the fire escape and route to the registered manager, on our visit on day three we did not observe any actions being undertaken or a plan in place with action in progress to make the passage accessible. After day three on-site we made a referral to the Merseyside Fire Service regarding these concerns. Upon the second and third on site visit we did not observe any improvements in the environment in relation to areas of safety concerns we had highlighted to the registered manager. Due to the absence of a governance process and a robust auditing process the provider did not have oversight of detection and control of potential risks and a description of how these identified risks were to be mitigated in and around the care environment.

The provider was asked to provide Health and safety risk assessments associated with the environment for people, this included in peoples care plans, these were not provided. We requested to observe an environmental risk assessment to cover the internal and external use of the property, this was not provided. We requested to observe a business continuity plan, this was also to include responses to extreme weather events, what we were provided to observe was not robust to identify the support required for people in emergency events. We requested evidence of a fire risk assessment for the premises, we were not provided this or evidence of a fire system test including a fire panel assessment. The provider has not maintained records of fire service visits to the premises including records of identified actions. Records showed a fire evacuation test had not been undertaken since 31 January 2023. The provider had not risk assessed equipment presenting a fire risk including portable heaters located in peoples bedrooms and in communal areas. The provider has not ensured the undertaking of assessments or taken all reasonable steps mitigate the risk of fire. Personal emergency evacuation plans were in two areas of the premises. Neither set of plans included an assessment or plan of how staff should respond during day shifts and night shifts when there was significant difference in staffing levels. Neither set of personal emergency evacuation plans had been reviewed within the previous 12 months. The provider failed to assess or managed the risks presented to people by the equipment used to deliver care in the service. The provider did not provide evidence showing routine and regular checks of equipment including but not limited to pressure mattresses, window restrictors, handrails and slings. Two profiling beds and a shower chair did not have a Lifting Operations and Lifting Equipment Regulations (LOLER) certificate.

People were asked if they like the staff at Seabank House, the responses seem to indicate that they did from glancing over to support staff and smiling and another person stating 'Yes they are helpful'. Another person we asked if they liked the staff said, 'Yes I do they are nice'. We were unable to judge and evidence through conversations if the people residing at Seabank House felt that the staff supporting them were qualified, skilled and experienced people, who receive effective support, supervision and development from the provider.

While holding discussions with the registered manager when asked regarding the recruitment of staff, we were provided a recent employee file, the file was not sufficient to ensure safe recruitment. The registered manager described a recruit who was to be on duty with a buddy system and shadowing period and described what this entailed. When the registered manager was asked about staff supervisions and appraisals, we were told that these had only been introduced since January 2024.There was no record of staff supervisions, continued personal development and appraisals prior to January 2024 and we were not provided a sample of supervisions as requested to observe to corroborate what was fed back from the registered manager regarding the medication competencies as the registered manager fed back that the medication competencies were included with the supervision records.

Rotas observed showed periods of time where there was one staff member on duty from 10am through to 2pm on a number of days, we observed on our first on site assessment day that one staff member was supporting 6 people and two of those people required full support to get ready for the day and observed support staff behind a closed door providing care and support for a while leaving no staff available to support other people if required in a timely manner. Our observations of unsafe practice with moving and handling of one-person by way of drag-lifting, inappropriate use of equipment for another person and lack of training records evidence determined that the provider was not ensuring skilled and competent staff through training, who receive effective support, supervision and development.

The provider had not ensured all staff have the appropriate training and supervision required to meet the specific care needs of people. The training certificates in staff files showed staff had completed up to 13 training courses within a single day including moving and handling and basic life support. The provider did not maintain a record of training renewal dates although the provider told us during the on-site assessment that all courses were renewed on an annual basis. The provider could not provide a training matrix showing all staff had received appropriate training within the last twelve months. We requested to be provided a copy of e-learning training schedules detailing the full range of training staff are required to undertake, the provider did not provide this information. This exposes people to the risk of harm because the provider could not provide evidence to show staff had the training and competencies required to provide safe care. The provider has not ensured staff have the additional training required to support people with specific care needs. The provider has not ensured staff have the training required to provide care for people receiving care in the service including those with epilepsy, diabetes, dementia, autism, Celiacs disease and learning disabilities. The provider has not provided evidence showing staff had the training required to meet specific communication needs including Makaton which was used by a person. The provider had not maintained evidence of ongoing assessment of staff to ensure that they are fit and proper for their roles. The provider had not risk assessed or produced a policy specifically identifying the frequency of DBS checks. The provider could not provide evidence of a DBS check for the registered manager which was requested to be viewed. The provider had not continued to ensure staff are fit and proper for their roles by rechecking DBS status or undertaking alternative action.

One person we spoke to seemed happy to be getting a new floor covering soon in their bedroom, when asked if they were happy about that they nodded their head and on day 3 we observed that their floor was much cleaner than day one visit, their floor was covered on day one on-site visit in chocolate biscuit crumbs. We visited another person’s bedroom and they stated that they kept their room tidy and liked their room exactly as it was. We asked another person if they helped with the cleaning of the kitchen, they said 'Yes, I am doing the dishes', and when visiting their bedroom, they stated that their room was tidy and stated that they liked the view from their bedroom. When we spoke to another person and asked them if they were happy with their room and how clean it was, they did not respond.

Discussions with the registered manager highlighted the checklists that had recently been introduced to improve the hygiene and cleanliness were not effective, not describing what was required and no records of deep cleaning taking place, staff were not completing the checklist fully, there were gaps present in the paperwork from week to week where bedrooms and areas of the home were not being cleaned. The registered manager stated that they had spoken to all the staff regarding the new paperwork, and that monitoring was taking place.

During our site visits, the premises were visually dirty, cluttered and poorly maintained. The kitchen and kitchen equipment were visually unclean. The kitchen oven had not been cleaned and the inside was thick with grease and burnt food. Kitchen areas were dirty including worktops and food preparation areas. Bins were not covered. The kitchen was used to store garden equipment. The hand wash sink was used by people to prepare beverages. We raised concerns about the poor cleanliness of the kitchen and kitchen equipment during our first visit. The provider took no action to clean the kitchen prior to our follow-up visits on 16 May 2024 or 21 May 2024. This exposes people to the risk of harm because poor cleaning practices expose people to increased risk of infection and illness. There was a storage room adjoining the kitchen, this was unlocked and accessible to people. The ceiling had partially collapsed in this storage room with insulation hanging from a hole in the ceiling and debris on the floor. The room was dirty and cluttered and smelt strongly of damp. There were open tins of paint stored next to incontinence products and nutritional supplement drinks. This exposes people to the risk of harm because poor cleaning practices exposes people to increased risk of infection and illness. When we spoke to another person and asked them if they were happy with their room and how clean it was, they did not respond, they seemed agitated about their own TV not working, this was also in front of the registered manager before they left to attend to something, the person was in their pyjamas, not had personal care support and their bed was unmade and had copper coins on the bed they had been going through.

The provider had not acted to address all issues identified through infection prevention and control audits undertaken by external agencies. The infection prevention and control audit for 16 November 2023 showed the service scored 21% compliance. A re-audit undertaken on 14 March 2024 showed the service scored 48% compliance. The re-audit showed persistent areas of non-compliance including urgent actions which had not been addressed by the time of our assessment. The provider had not reviewed the environment, removed inappropriate items including boxes in hallways, or implemented a robust and comprehensive daily cleaning schedules and auditing process. Environmental programme of repairs/replacements for improvements was not in place. Storage areas were not cleaned, and repairs were not completed. Storage areas were not included in a robust cleaning schedule. Actions required in relation to handling and disposal of linen were not achieved including separation of dirty and clean linen, repairing ventilation systems, or purchasing new laundry washing equipment. Staff training in relation to infection prevention and control including competency checks were not completed. The provider had not addressed these areas by the time of our third visit. Cleaning records were not maintained to evidence that areas were appropriately cleaned or deep cleaned as required. The Infection Prevention and Control policy and procedure held in the service is ineffective and does not provide appropriate guidance and operating processes for staff to follow.

We observed a person taking their medication, they preferred a routine of having their morning medication at the dining table with breakfast. We observed another person going to the medication room unprompted with the drink they had made for themselves, they were given their medication to take, this seemed like it was their preferred morning routine as they went to the kitchen after receiving their medication in a pot to take, we observed a staff member followed them to observe and then asking for the pot back.

The registered manager stated that medication competency assessments were recently undertaken for staff, and these were undertaken with the supervision of staff processes. The registered manager told us that a senior carer was 'train the trainer' trained and delivered the medication training and completed staff medication competencies. When we requested the medication competency records and evidence of staff training, we were not provided this. When we observed the senior carers certification for train the trainer course, we could only evidence that they had completed train the trainer course for the mental capacity act from 02 July 2020.

The provider did not ensure the safe storage and management of medication. The provider could not provide evidence of staff training and competency in medication management. This was requested verbally on-site and by follow up by email. The provider could not provide when requested evidence to show the medicines trainer in the service had the skills and qualifications necessary to undertake this role or to sign off other staff as competent. This exposes people to the risk of harm because the provider could not provide evidence to show staff had the skills and competencies necessary to support people with their medication. Medications were not labelled appropriately including liquid medications and creams which did not have the dates specifying when they were opened. This was a risk to people because medications could be used after they had expired. Guidance for staff for how to use topical medications was not available and records including body maps were not used. This exposes people to the risk of harm because staff did not have appropriate guidance or follow processes to support the administration of medication appropriately. Medications were not stock checked or audited. PRN (as required medication) was not checked regularly, and PRN protocols were not available in some instances and medication risk assessments and care plans were not available for people. This exposes people to the risk of harm because this risked staff failing to provide or inappropriately providing as required medication. We observed prescribed medication in Room 8 (an unoccupied bedroom) was not locked and was accessible to staff and people. Room 8 contained medication overflow cabinets. The room and the cabinets were open on day one of the on-site assessment and a large storage tub of prescribed supplement drinks, most of the cabinet doors were left unlocked and accessible. On our third day of on-site assessment, we found the cabinets in room 8 were still unlocked.