Serene Healthcare Services Ltd

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.

This is the first assessment for this registered service. This key question has been rated 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 was in breach of legal regulation in relation to governance at the service.
 

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Leaders and staff were able to tell us about the vision and values for the company. One staff member told us, “The visionof the company is to offer high quality and professional care to our clients. This includes the wish for our clientsto live in their own homes if they so wish and gain independence. To do this the company gives good qualitytraining to the staff and carry out supervision. They also promote open communicationso that they can pick up on issues and improve.”

Leaders were compassionate and inclusive. Following an emergency, leaders had significantly adapted their model of care to ensure people’s needs could be met safely. Staff told us they felt leaders were capable and compassionate. One staff member said, “They have been running a companyfor long, so they know how to treat and communicatewith staff and clients.” The manager and the director had completed a Level 5 qualification in Health and Social Care Leadership and had good oversight of the service.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. However, leaders had not identified that records were outdated and had not ensured audits were effective in driving improvements at the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff told us they felt able to speak up and raise any concerns if needed. One staff member said, “Freedomto speak up means that where I have any concerns or see an issue, I can raiseit with the managers, and if it's not acted on, I can take it further up like for example to the Local Safeguardingor CQC or others.” There were policies in place which informed staff how they could contact other agencies if they were not satisfied with the response from the service.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff told us they felt “well treated and supported”. Leaders told us they facilitated any flexible working requests and annual leave requests from staff and staff confirmed this.

The provider did not have good governance. We identified concerns regarding the administration of medicines and capacity and consent, and internal governance systems had not identified this. We were provided with only one medicine audit; however, this had not been effective in identifying the concerns.

Some care plans and risk assessments were not up to date. Although this risk was reduced due to their being only 2 staff on a live in care arrangement, there was still a risk that new staff or temporary staff would follow incorrect guidance, which put people at risk of harm.

Although there were policies and procedures, these at times referenced outdated information and were in some cases not followed. For example, one policy referenced CQC’s previous inspection framework. There was a policy for consent to care and treatment which stated consent should be obtained and recorded where possible, or a capacity assessment and best interest decision will be carried out where people lack capacity. However, there was no evidence that consent had been obtained for the 2 people receiving regulated care.

However, staff and people’s relative felt the service was well managed. Staff were clear about their roles and responsibilities.

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. The service worked well with healthcare agencies. We saw positive feedback from a healthcare professional praising the manager, which stated,; “[Manager] was truly exceptional. She had a wonderfully calming effect on both patients, and nothing was too much effort for her. The [people] were extremely lucky to have [manager] by their side, and she is undoubtedly a credit to your company.” Leaders told us they worked well with another care provider and told us they shared learning with each other to improve their service. The manager told us, “[Care provider] mentioned there’s a group [care provider] run, where we talk to each other and exchange information. We are looking into joining those meetings.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. Leaders told us they kept up to date with information which affected the delivery of care. Leaders also told us they had recently upgraded their office space to somewhere more modern and spacious. They told us they felt this was a better working environment. Leaders used an online care planning system to ensure better oversight of the service. This alerted them to any missed care entries or late records of care.