CQC report explained · a residential care home
What the CQC found at Seeleys House Short Breaks Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and managed, records were accurate and up to date, staffing was sufficient, and medicines and infection control were handled safely.
- Effective?
- Good
- People received personalised support, help with food and drink, suitable staff training, and support to make decisions. Inspectors found improvements in mental capacity assessments and care planning.
- Caring?
- Good
- This question was not inspected during this visit. The report says people appeared relaxed and received kind and compassionate care, but the previous rating was carried forward.
- Responsive?
- Good
- This question was not inspected during this visit. The report says care plans reflected people's needs, wishes and goals, but the previous rating was carried forward.
- Well-led?
- Good
- Inspectors found a clear management structure, effective checks on quality and risk, approachable managers, and a positive culture focused on people's needs.
What inspectors found, February 2023
Rated Good; inspectors found safe, kind and personalised care, with a small shortfall in some staff supervision meetings.
This was an unannounced focused inspection on 25 and 26 January 2023. One inspector visited the home, while an Expert by Experience contacted people and relatives. Inspectors spoke with people, relatives and staff, and reviewed care records, medicines records, audits and policies.
The home was rated Good overall. Safe, Effective and Well-led were all rated Good. Inspectors found that people were supported safely, staff understood their needs, and care plans and risk records had improved. People appeared relaxed and enjoyed their stays. Relatives described staff as professional, friendly and caring.
This inspection checked whether earlier problems had been fixed. The previous rating was Requires Improvement, with breaches of regulations. Inspectors found enough improvement and said the home was no longer in breach. Caring and Responsive were not inspected during this visit, so their earlier ratings were used in the overall rating.
Safe support
Risks were assessed and managed well. Inspectors found suitable staffing, safe medicines systems, good infection control and learning from incidents.
“People lived safely and free from unwarranted restrictions because the service assessed, monitored and managed safety well.” from the report
Kind communication
Staff understood different ways of communicating, including gestures, sounds, Makaton, pictures and symbols. People were observed to be smiling, laughing and relaxed.
“People received kind and compassionate care from staff who used positive, respectful language which people understood and responded well to.” from the report
Personalised care
Care plans included people's health needs, communication methods, preferences, strengths and longer-term goals. Staff supported people to build independence.
“People had care and support plans that were personalised, holistic, strengths-based and reflected their needs and aspirations, included physical and mental health needs.” from the report
Supportive leadership
Managers were visible and approachable. Governance checks had improved and staff understood the home's values and their responsibilities.
“Governance processes were effective and helped to hold staff to account, keep people safe, protect people's rights and provide good quality care and support” from the report
Supervision timing
needs fixingSome staff had not met their line manager as often as the provider's policy required. The registered manager knew about this and was trying to ensure meetings happened on time.
“Some staff had not met with their line manager at the frequency set out in the provider's policy.” from the report
- 01How will you match staff to my relative's communication system, sensory needs and personal preferences?
- 02How will you support my relative to make choices and remain as independent as possible during a short break?
- 03How do you check and record medicines before each admission, especially if medicines or instructions have changed?
- 04How often will staff supporting my relative receive supervision and training?
- 05How will you involve our family in reviewing the care plan and raising concerns?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 24 February 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, July 2019
Seeleys House Short Breaks Centre was Rated Requires Improvement; inspectors found kind, personalised care but serious gaps in risk management, consent and oversight.
Inspectors visited without notice on 16 and 20 May 2019. They spoke with people, relatives, staff and managers. They reviewed care records, medicines, staff files, complaints and safety checks. They also watched routines, breakfast and a staff handover.
People were generally treated with kindness and respect. Relatives praised improvements and said staff understood people's needs, preferences and interests. People had access to activities and support to use local services.
However, people were not always protected from avoidable harm. A person at high risk of choking was not safely supervised while eating. Risk information was sometimes missing, inaccurate or not readily available to staff. Records of drinks were also not always complete.
The home did not consistently follow the Mental Capacity Act when using restrictions or making decisions for people who could not decide for themselves. Quality checks had identified some problems but had not always led to prompt action. The overall rating and the Safe, Effective and Well-led ratings were Requires Improvement. Caring and Responsive were rated Good.
Kind and respectful care
Inspectors observed positive interactions. Relatives said their family members were treated kindly and enjoyed their stays.
“People were treated with dignity and respect. Relatives told us they were happy with how their family member was supported.” from the report
Personalised support
Staff knew people's routines, likes and dislikes. Care plans included individual preferences and communication needs.
“People were supported by staff who were knowledgeable about their likes and dislikes.” from the report
Activities and choice
People were supported to take part in activities they chose, including visits to shops, the local area and the cinema.
“People had access to activities of their choice.” from the report
Medicines and infection control
Medicines were stored and administered safely during the inspection. The home was clean and had systems to reduce infection risks.
“We observed staff followed safe practices when they administered medicines.” from the report
Staff training and recruitment
The home used safe recruitment procedures and gave staff induction, training, supervision and additional training where needed.
“People were supported by care workers who had the skills and knowledge to meet their care needs.” from the report
Choking and other safety risks
seriousA person at high risk of choking was observed eating without safe supervision. Risk assessments did not always include professional advice or give staff clear, available instructions.
“People were not routinely protected from avoidable harm.” from the report
Mental capacity and restrictive practices
seriousThe home did not consistently complete or record mental capacity and best-interest decisions for restrictions such as bed rails and a wheelchair lap belt.
“We found mixed practice regarding the application of the MCA.” from the report
Quality checks were not effective enough
seriousAudits repeatedly identified missing mental capacity assessments and other record gaps, but these were not corrected promptly.
“Quality audits did not always drive improvement in a timely manner.” from the report
Care and fluid records
needs fixingSome care plans needing updates had not been changed. One person's records showed no drink recorded for a 12-hour period, so inspectors could not be reassured that enough fluid had been given.
“One person's record showed they had regularly gone 12 hours without a drink being recorded.” from the report
Staffing at meal times
needs fixingInspectors and staff said more staff were needed to support people, especially during meals. The manager said staffing had been increased on the second inspection day.
“People were not always supported by enough staff to meet their needs.” from the report
- 01How will you make sure staff can immediately find and follow each person's current choking, pressure damage and bed rail risk assessments?
- 02What checks are now in place to ensure mental capacity assessments and best-interest decisions are completed before restrictive practices are used?
- 03How do you monitor drinks and other care records during a short stay, and what happens if a record is incomplete?
- 04What staffing levels are provided at meal times for people with complex needs?
- 05What improvements have been made in response to the Warning Notices for safe care and good governance?
This was an unannounced comprehensive inspection covering all five CQC questions, with site visits on 16 and 20 May 2019; it followed up the Requires Improvement rating from February 2018. This explanation was written from the published report of 27 July 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Seeleys House Short Breaks Centre
4 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- February 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Seeleys House Short Breaks Centre →
- July 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
Read what inspectors found at Seeleys House Short Breaks Centre →
- June 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- May 2017
Registered with the Care Quality Commission on 5 May 2017.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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