Seraphim Home Care

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment, we rated this key question inadequate. At this assessment the rating remains the same. This meant there were shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider had met most of the concerns identified in the warning notice they were served. However, further improvements were still needed and the provider continued to be in breach of legal regulation in relation to good governance.

This service scored 32 (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.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes. The service did not have a service improvement plan. The provider had created a document titled, ‘non-conformance register’ to list areas identified for improvement. No information had yet been added. For example, shortfalls identified at previous assessments. An audit plan of key documents and policies showed what month in the year these would be reviewed. An internal audit report document outlined what areas would be considered and actions to take forward. However, this had only been completed for the mission statement. A mission statement outlines the organisations key aims. The internal audit report did not include other documents such as the statement of purpose or service user guide which had been amended since the last assessment. This meant it did not show what had been changed.

The provider had created a quarterly quality monitoring document. This audit reviewed safeguarding, risk management, incidents and accidents, training and staffing. Patterns and trends relating to incidents and accidents were included. However, the use of this document had not yet been embedded.

The provider had updated key documents such as the service user guide, complaints and compliments policy and their statement of purpose which had been submitted to Care Quality Commission (CQC) as required. The quality and safety assurance policy had not been updated.

Information relating to safeguarding, complaints and accidents and incidents was organised and reviewed. There were no recorded incidents of missed medicines. Medicine audits required further development to ensure all aspects of medicines management were fully assessed.

Staff had access to policies and procedures. Systems confirmed staff had read these. Policies and procedures were not always dated so staff would have been unclear if they were using the most up to date version. Information gathered from the August 2024 service user questionnaire had not been used to make improvements to the service. A new service user questionnaire had been devised and the service planned to send it out to people shortly.

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.