Serene Healthcare Services Ltd

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment for this registered service. This key question has been rated good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

This service scored 67 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. The manager had completed a comprehensive assessment of people’s needs prior to them receiving support. This included obtaining information about their likes, dislikes, background and religion. People’s relatives confirmed they were involved in the care planning process.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them. There were no records to demonstrate any formal reviews of people’s care had taken place at the service. Additionally, care plans and risk assessments had not been updated to reflect changes to people’s needs. This meant there was a risk of people’s needs not being met.

However, a relative told us the service was regularly communicating with them and told us the service amended their care delivery based on changing needs, despite records being outdated. Staff told us care was evidence based because they knew people well.

The provider worked well across teams and services to support people. There was a small team at the service, however, staff told us they worked well together and told us communication was effective. A staff member said, “Since we have only two clients, we keep in touch with the manager, the director and colleagues by messages and calls. I write notes during care on the digital application (handover notes) which the other carer reads to know how the clients are doing.” People’s relatives told us staff worked well together and with other organisations, such as the GP.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support. There was information in people’s care and support plans to encourage a healthy lifestyle. For example, care plans stated, ‘Encourage a healthy breakfast’ and ‘I need to be reminded to drink to keep me hydrated.’. Staff supported people to access healthcare services when they needed it. A relative told us staff were “very good at calling the ambulance straight away” when this was required for one person. Staff confirmed they supported people to access other services such as the GP, and the memory clinic.

The provider routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. Staff monitored people’s needs when this was required. One person was at risk of dehydration. Leaders and staff told us there were monitoring records in place following this to ensure the person was receiving adequate fluids. However, the person’s care plan had not been updated to reflect this. A relative told us they felt people’s needs were well monitored. They said, “Staff definitely monitor their health needs well.”

The provider did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment. There was no evidence the service had sought formal consent before delivering care to people. We asked leaders about this who confirmed people did not have capacity to consent to their care and treatment. However, a mental capacity assessment and best interest decision had not been formally completed to decide if this was in people’s best interest.

However, relatives were able to confirm that discussions had taken place and that people did consent to their care. A relative told us, “If there were any issues with the care my [relative] would be able to tell me.”

Staff had completed training in the Mental Capacity Act and were able to explain how they followed this in their role.