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 has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.The service had made improvements and was no longer in breach of legal regulations in relation to good governance, statement of purpose, fees, display of ratings and notification of other incidents.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a fully shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. The provider was working towards understanding the challenges and the needs of people and their communities. The provider had further work to do in developing and embedding the service’s direction and culture through stronger governance systems, enhanced staff and leader training and organisational development. The service user guide, statement of purpose and mission statement described the service’s aims of delivering person centred care. Staff we spoke with reflected these aims. A staff member said, “We are all here for the same reason to make sure they [service users] are safe, happy and looked after.” The manager had promoted a listening culture which promoted trust and understanding between them and people using the service. One person said, “They are excellent, it`s a friendly service from top to bottom.” The service was improving, focusing on positive outcomes for people and valuing and engaging with staff. People and staff were now listened to and actions taken to ensure a positive culture remained. A staff member said, “They’re good on communicating, and just generally they try to make everyone happy and they genuinely care about their staff.” A person said, “They have high standards. We just ring up and any query is dealt with straight away.”

Leaders understood the context in which the provider delivered care, treatment and support. They were working towards embodying the culture and values of their workforce and organisation. Leaders were building on their skills, knowledge and experience to be able to lead effectively. Leaders were acting with integrity, openness and honesty. The provider still needed to expand their knowledge and understanding around effective governance to ensure the service was safe and continued to develop. Leaders were planning to attend external training around governance, data security and management of staff.

Staff, people and relatives spoke highly of the manager and impact they had on the service. The manager was visible and approachable. The manager led by example, ensuring positive relationship with people who used the service and their families. A staff member said, “[Name of manager] has been amazing. Everything seems to be dealt with. Nothing is too much trouble. They will always follow up with things.” People told us, “The manager is very approachable,” and “The manager is great.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had made significant improvements to ensure people and staff could speak up and be heard. The manager had worked to develop the organisational culture and to make sure people felt confident their concerns would be listened to and addressed. Systems enabled staff to raise concerns through supervisions, staff meetings, surveys and communication with office staff. Staff could give feedback anonymously. A staff member said, “If we have an idea we can have our say.” Leaders acted in an open and transparent manner. When something had gone wrong this was acknowledged and an apology made where appropriate.

The provider valued diversity in their workforce. However, leaders did not always actively work towards an inclusive and fair culture by improving equality and equity for people who worked for them. The service had an equality, diversity and inclusion policy. Information around people’s protected characteristics was gathered during the recruitment process. However, this information was not used in a meaningful way to assess and review diversity and inclusion. Staff told us the organisation treated people fairly and were respectful of different cultures, ages and genders. A staff member said, “Everyone is different, carers and the service users. There is no discrimination and there should not be in any job. People respect each other and do their job.” A relative said, “Everyone is very respectful.”

The provider did not always have systems of good governance. They did not always act on the best information about risk, performance and outcomes. Improvements had been made to provider oversight and governance systems. However, these still required further improvement to be fully robust, identify areas for improvement promptly and monitor progress. For example, the shortfalls in recruitment and evidence of catheter care training. The provider did not fully scrutinise care plans and risk assessments in their audits to ensure the quality of information was reviewed. The service did not fully evidence how it planned to develop and progress in areas which had been previously identified for improvement. Training for leaders in effective governance had not yet occurred. A manager had not been registered with CQC as a condition of the providers registration since October 2023. The manager submitted their application after this assessment.

Key documents had been reviewed and updated. For example, the statement of purpose and organisational policies and procedures. The updated statement of purpose had been submitted to CQC. Systems to manage accident, incidents and safeguarding concerns and ensure appropriate actions had been taken had been improved. Information was now submitted to the local authority and CQC as required. The provider had displayed is CQC assessment rating at the location. The provider did not currently have a website. The provider had amended and circulated documents such as service users’ contracts, fees and terms of service to ensure these included the agreed cost of care and support hours being provided. People we spoke with had access to these.

People’s feedback had been sought in reviews and telephone conversations. A person said, “In the past 6 months there has been a big improvement, carers are now generally on time.” Staff told us the service had improved. A staff member said, “It is better now than what it used to be.” A staff member said, “They are on the ball with everything. You ring the office with an issue and you know it will be dealt with.”

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Progress had been made in working with partners to improve outcomes for people. This involved liaising with social workers, district nurses and the local authority. A health and social care professional said, “We have seen improvements in the provider since the last inspection.” Further development of leadership skills would enhance the providers community network and support keeping up to date with good practice.

Improvements were being made in how the provider focused on continuous learning, and innovation. Staff were encouraged to give feedback and collaborate in suggested approaches to working with people. Governance systems needed improvement to ensure areas were identified for development within the service and to continue to move the organisation forward. This included enhanced training for staff and leaders. Surveys were completed to gain feedback from people and staff.