Serene Healthcare Services Ltd

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this registered service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to the ways people’s medicines were managed.

This service scored 62 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. At the time of the inspection, there were only 2 people receiving a regulated activity. This meant there were only a small number of incidents which had occurred at the service. We found there was no formal process to review incidents and accidents. However, clear actions had been taken following incidents, and the service was able to demonstrate how they had learned from these. Leaders told us they would implement a clearer process as they supported more people.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. A person’s relative told us staff at the service had supported their family members when they were admitted to hospital following an accident. The relative told us, “[The registered manager] was good at liaising with the doctors there and advocating for them.” Leaders told us they sent relevant documentation where needed with people when they were admitted to hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately. There had not been any safeguarding concerns at the service at the time of the inspection. However, leaders told us the process they would follow. There was a safeguarding policy in place which clearly outlined procedures for staff to follow in the event of a safeguarding concern. A person’s relative told us they felt people were safe and told us their family member would be able to tell them if they had any concerns. The relative told us there had not been any concerns raised. Staff had received training in safeguarding.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Some people’s risk assessments and care plans contained incorrect and outdated information. For example, one person was identified to be at risk of dehydration following a hospital admission. Leaders had implemented a process for staff to monitor the person’s fluids. However, there was no information in the person’s care plan or risk assessment about this. This meant there was a risk that staff would not follow the correct procedures. However, relative’s felt people’s risks were well managed. There were risk assessments for people for other aspects of care, and these were detailed.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The service had assessed the environmental risks relating to fire safety where live in care was provided, and there was information within people’s care and support plans to guide staff to stay safe within the environment. The service operated a lone working policy, and there was a lone worker policy and training for staff. Staff working in a lone working setting had a risk assessment in place to support the management of risks relating to working alone. There was a fire safety assessment for the service’s registered office.

The provider did not always make sure there were enough qualified, skilled and experienced staff. Staff had received training relevant to their roles, however there was no evidence leaders had checked staff’s competence in relation to administering medicines and insulin. This meant leaders could not be assured that staff were administering medicines, including insulin safely.

Overall, staff had been recruited safely. However, it was difficult to ascertain whether one staff member had gaps in their employment history as they had only recorded the years of their employment. This meant the service could not be assured they had one staff member’s full employment history.

However, staff had received supervisions and appraisals where appropriate. Staff told us they felt supported in their roles and had no concerns.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff had completed training in infection, prevention and control. Leaders and staff told us sufficient personal protective equipment was available for use when required. A person’s relative told us they felt staff supported their family member to keep their environment clean. There was an infection prevention and control policy which outlined procedures for staff.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We identified a number of issues regarding the administration of medicines. We found Medication Administration Records (MARs) were not up to date and included incorrect information. This included recording a person had no allergies despite them taking medicines for allergies. Additionally, a person’s MAR had not been updated to reflect that staff were required to administer a specialist medicine which had previously been self-administered by the person.

There was also no guidance for staff on how to administer this medicine in the person’s care and support plan. However, there was a separate document outside of the care plan which outlined how to carry out this role. Furthermore, there was no evidence from a health professional stating they were happy to assign this task to care staff. The manager told us district nurses carried out an assessment for staff and reassigned this. However, there was no evidence of this at the time of inspection. This meant staff were administering specialist medicines without any formal agreement in place.

There was no evidence the service had sought consent for staff administering people’s medicines. We were informed the people using the service lacked capacity to consent to their care and treatment, but there was no evidence of a mental capacity assessment to assess this, nor a corresponding best interest decision. This meant staff were administering medicines to people without any formal consent.

Although staff had completed training in medicines, there was no evidence leaders had completed any formal competency checks for the administration of medicines, including insulin. The manager told us they had checked staff’s competence but there was no record of this. This meant there was a risk that staff were incorrectly administering medicines including insulin.

The risks above were reduced because there were only 2 staff working at the service who knew people well. Leaders told us they were regularly at the service informally observing staff and had found no concerns. We saw evidence of a recent review from district nurses which stated they were happy with how a person’s insulin was being administered