Archived: Seabank House

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

The provider did not have oversight of the service and had failed to ensure effective support and leadership. The provider did not have effective governance or robust systems and processes to identify, assess, record, manage and mitigate risks in the delivery of the service. The provider failed to maintain accurate and complete records in respect of people's care and of decisions taken in relation to the care provided to them. The provider did not always plan, promote or ensure people received person centred and high-quality care with good outcomes. The lack of robust care planning, monitoring and reviewing of people's care placed them at risk of harm. The provider did not evidence how the staff team were supported and encouraged to improve their learning and development and was unable to demonstrate how the service was evidencing and recording improvement and innovation. The provider did not evidence a clear vision for the direction of the service which should have demonstrated ambition and a desire for people to achieve the best outcomes possible. The provider did not promote a culture that encouraged candour and openness. The provider failed to act upon concerns in an open and transparent way when accidents, incidents and near misses occurred at the service, for example, injuries and hospitalisation were not recorded to evidence how they were managed, Safeguarding concerns not recorded or managed appropriately to evidence how they were managed, these incidents had not been notified to the Care Quality Commission by the provider.

This service scored 25 (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 was provided a document to complete a comprehensive response to questions to describe and help us understand how they promote a shared vision, strategy, and culture. A deadline was also provided for this response, the deadline passed, we did not receive the response as requested.

The provider did not hold meetings or provide alternative ways to share a vision or direction or monitor culture within the service. Meeting minutes could not be provided, and the registered manager told us meetings had only been introduced in January 2024. The provider did not have a process in place to gather staff and peoples feedback to understand the challenges and the needs of people and their communities in order to meet these.

The registered manager was provided a document to complete a comprehensive response to describe and help us to understand how they understand the context in which they deliver care, treatment and support and embody the culture and values of their workforce and organisation. A deadline was also provided for this response, the deadline passed, we did not receive the response as requested.

During the on-site assessment process, the provider was unable to identify or provide evidence of a leadership and governance process. There had been lack of accountability, responsibility and scrutiny at all levels which impacted on people's safety and the quality of service. This included the absence of a robust recruitment processes and induction processes, staff recruitment files observed did not evidence that staff had the appropriate training and signed off as competent to undertake their roles, this was also impacted by the absence of probation meeting notes and supervision records. Also, during the assessment process, we were not assured that the provider was effective, and we were not assured that they had the skills and knowledge to lead effectively as requests for information and evidence of processes were not considered, absent or not available or not provided by a deadline date provided.

Discussion with the registered manager when walking around the service on day one, while looking at an information board, the registered manager was asked about considering displaying information to support people, staff, visitors, and family members to educate regarding the freedom to speak up process, the registered manager was not aware of the 'speak up guardian' process that can be introduced to a service. We did not speak to staff regarding this matter.

The provider did not ensure robust mechanisms to seek and respond to staff feedback. There was an absence of provider led audits, outcomes and improvement plans. There was an absence of information to educate, encourage and promote knowledge and empowerment for staff and people to use the freedom to speak up process, the service did not have any visual posters or information to promote and encourage people, visitors and staff to feel that they can speak up and that their voice will be heard.

Through discussions with the provider, they stated that they had only introduced supervisions and team meetings since January 2024, it was difficult to evidence that staff voices were captured through supervisions, appraisals, and a staff survey process. The provider could not evidence how they work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider did not have a robust auditing and reviewing process that could consider and measure their performance regarding workforce equality, diversity, and inclusion. We were not provided an overview or screenshots of staff training from online e-learning courses when we asked for these, the provider could not evidence if they ensured equality, diversity and inclusion training.

The registered manager was provided a document to complete a comprehensive response to describe and help us to understand how they provide clear responsibilities, roles, systems of accountability and good governance. A deadline was also provided for this response, the deadline passed, we did not receive the response as requested.

The provider did not have effective governance or systems and processes to identify, assess, record, manage and mitigate risks in the delivery of the service. Systems had not operated effectively to identify the risks found by the inspection team. The provider did not demonstrate insight into the risks or could not produce evidence that there were effective action plans to address the identified risks. The provider failed to act on areas for improvement identified by external agencies including the infection prevention and control teams and the quality improvement team provided by the Local Authority. The provider failed to act to make improvements following feedback from our visits during the on-site assessment, the provider had failed repeatedly to act to make improvements to the service and mitigate the risk of harm to people. The provider had not implemented effective audits of care records to identify areas for improvement. They had not identified the issues found in care records including poor risk assessment and management. This exposes people to the risk of harm because staff did not have appropriate risk assessments and care plans to follow to provide safe care meeting the current needs of people. The provider had not implemented effective systems and processes to ensure where action is required, to ensure premises and equipment are clean, well-maintained, and fit for purpose and had not implemented effective environmental risk assessments. The provider had not maintained appropriate records to evidence compliance with health, safety and fire requirements. This exposes people to the risk of harm because they have not assessed and taken all reasonable steps to ensure the premises were safe, particularly in relation to the risk of fire. The provider had not ensured the service submits statutory notifications as required to CQC. This includes allegations of abuse, and incidents where people have been injured.

We did not receive positive or negative comments from people using the service in relation to partnership working. We did evidence engagement from visiting professionals with the people residing at Seabank House.

The registered manager was asked to complete a comprehensive response and a deadline provided to help us to understand how the provider undertakes their duty to collaborate and work in partnership, share information and learning with partners and collaborate for improvement, the deadline has passed, and we have not received the response. Discussions were held with the provider in relation to working with external professionals to support improving the service, The registered manager stated that a lot of actions had been undertaken to achieve the actions required that were identified from the PAMMS assessment and the Infection prevention and Control team and stated that there was a number of other actions to be completed.

Feedback from partners highlighted the provider was not working in partnership to promote the services to work seamlessly for people.

Due to the lack of governance systems the provider had not operated effectively to identify the risks found by the inspection team. The provider did not demonstrate insight into the risks or could not produce evidence that there were effective action plans to address the identified risks. The provider failed to act on areas for improvement identified by external agencies including infection prevention and control teams and quality improvement teams provided by the local authority. The provider failed to act to make improvements following feedback from our first visit and second visit. This exposes people to the risk of harm because the provider had failed repeatedly to act to make improvements and work with external partners to improve the service and mitigate the risk of harm to people. The provider did not have a feedback gathering process for people and their families and loved ones in a formal process to collaborate for improvement.

Discussion with the registered manager at the service evidenced that there is not 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 to continuously learn, innovate and deliver improvements. The registered manager was asked to provide and complete a comprehensive response to describe how the service embraces learning, improvement, and innovation. A deadline was also provided for this response, the deadline passed, we did not receive the response as requested.

The provider failed to evidence processes to embed learning and making improvements. There was the absence of robust auditing and quality assurance process, there was no information available or provided to evidence incident learning and a thorough review process after incidents, this also extended to care planning and risk assessments that were not reviewed after incidents. The provider did not have a quality improvement plan or a strategy to embrace and instil continuous learning, innovation, and improvement across the service. The provider was unable to evidence creative ways of delivering equality of experience, outcomes, and quality of life for people.