This unannounced comprehensive inspection took place on 5, 12 and 14 September 2018.

Seaview Haven is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Seaview Haven is a care home which previously belonged to the local authority. It has undergone an extensive refurbishment and provides a high standard of fixtures and fittings. This was the provider’s first inspection.

The service was registered for 29 people. There were 27 people living at the home at the time of inspection, many of whom were living with dementia. Seaview Haven is a care home situated in a residential area of Ilfracombe. It has accommodation sited over three floors, some rooms with extensive sea views. However, at the time of inspection the upper floor was not in use, except for one person who had chosen to live on that floor.

The service had a manager who had registered with the Care Quality Commission (CQC) in July 2018. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was supported by the nominated individual and the deputy manager who formed the management team. They had worked together for the previous four months.

The service had been registered with the CQC since October 2017. In that time, two other previous managers had led the service. However, both had left within a short space of time and had not been registered with CQC. This effectively meant that since the service was registered, it had operated without a stable registered manager in place until recently.

Despite the management team working closing together, there was a definite lack of leadership and oversight of the whole service. This was due in part because the management team had previously managed services with a different type of service user group with a different type of need.

People’s health, safety and welfare were put at risk because there were many risks to the environment, both inside and outside of the building. People’s individual risks had not always been assessed and managed in a safe way. There was a lack of quality monitoring and inconsistency in record keeping.

Because of the seriousness of the concerns found on the first day of inspection, we wrote to the provider and management team setting out our concerns. They recognised and acknowledged the concerns raised. They were upset and disappointed at the findings but agreed with the judgements. They recognised action was required and put together an action plan with timescales for action. They confirmed their commitment to addressing all concerns and their assurances to improve the safety of people living at the service. On the second and third day of inspection, all the concerns had a plan to put them right. Some of the work had already been completed and some areas made safe whilst a permanent fix was made. Health and social care professionals had been contacted and arrangements for assessments to be made.

People were not protected from unsafe and unsuitable premises. The provider’s quality assurance systems did not take place regularly and had therefore not picked up the deficits and shortfalls identified during the inspection. The provider had not completed an environmental risk assessment or monitoring checks to ensure the environment was safe. In particular, we highlighted risks due to open access to unsafe areas both inside and outside of the building. No monitoring checks had been undertaken in relation to bedrails and beds to ensure they were safe and at the correct settings for the individual person.