Seahorses

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

In this key question we looked at 2 quality statements. Systems and processes were not in place to enable effective oversight of the service, particularly in relation to safe care. We found a breach of regulation in relation to how the service was managed.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Managers did not have the skills and knowledge to lead a team effectively. We found widespread shortfalls in the delivery of people’s care and support, including systems and processes. For example, care plans contained limited information about people’s needs, risks and likes and dislikes. We found people did not have their medical histories recorded in their care plans, including people’s allergies. We observed this had an impact on a person living at Seahorses. During our assessment we received a safeguarding referral from the local ambulance service, due to a person being administered a medication which they were allergic to, as this was not clearly documented in the person’s care and support plan. We also found concerns relating to the effectiveness of audits which had been completed by the provider, such as infection prevention and control audits, management audits and accident and incident audits, which did not identify the concerns we found at time of the inspection.

Staff spoke positively about the management of the service and felt supported in their role. One staff told us: “They are very supportive towards all staff, me personally. [Owner] has noticed how well I'm doing and has put me forward to do [an external qualification]. If I ever felt not confident, you could speak to [management team], they would get you training straight away. If I didn't feel competent, they would support me to feel confident, they are a good team, very strong.”

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider could not explain to us about how their systems and processes around certain areas meant the service ran safely and effectively. For example, when we asked about ensuring people’s care plans include important information such as medical histories, the provider told us the doctor surgery has their own records, and could not see why it was important to have this information clearly documented. We also asked the provider about people’s hospital passports. These documents tell the hospital about people’s care and support needs. The provider told us people did not always have these in place because they had not yet been admitted to hospital. This meant that if a person required hospital admission, the document would not be readily available. We also raised concerns around people’s pressure area care at the time of the site visit, and the management team were not aware of their requirement to safely assess people’s pressure area risk. The provider explained they have now updated their training and have good communication with the district nurse team.

Audits were not effective at identifying areas for improvement within the service. We found various concerns during our assessment which had not been identified by the service. For example, accident and incident audits did not look at the details of incidents but instead looked at whether these had been appropriately recorded. This meant trends and themes could not be identified, making it difficult for any learning to take place. The managers audit did not follow a structure but was a list of events which had occurred the previous month. There was no clear system to ensure overall and consistent compliance within the service. Additionally, the infection prevention and control audit in place did not identify the concerns we found during our site visit.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.