Serenata Care Ltd Trading as Two Cedars

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 inspection for this provider. This key question has been rated requires improvement.

This meant some aspects of the provider were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to safe care and treatment.

This service scored 59 (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 always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice.

Staff recorded and reported accidents and incidents. Management investigated these. However, regular audits of accidents and incidents did not take place, which meant the provider was unable to identify any patterns of incidents to implement effective risk mitigation measures and learn lessons. This meant people were at risk of avoidable harm. Management told us they planned to complete monthly audits moving forward.

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 providers.

Peoples’ needs were assessed prior to moving into the home and a guide was in place to provide additional support for the transition process. There was a process in place to share information with external partners when people went into hospital.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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.

People told us they felt safe living at the home. Staff received safeguarding training and knew how to report any concerns. Safeguarding systems and processes were in place to identify, report and, investigate concerns.

The provider did not always work well with people to understand and manage risks. They 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.

Although care plans and risk assessments were in place and had been reviewed, some risk assessments did not provide enough information or guidance for staff to follow. For example, where people were at risk of falls, risk assessments did not include mitigating measures to reduce this risk. Records did not reflect how the provider worked with people or capture their views around their individual risks. As a result, guidance was not always in place to support individuals to manage risks in line with their needs and preferences.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The provider had instructed an external contractor, specialising in fire safety, to undertake a fire risk assessment. However, the provider failed to act and work in line with the risk assessment. High and medium severity actions had been identified, and records showed no action had been taken. Regular fire drills did not take place. This meant people were at increased risk of avoidable harm.

The provider did not work in line with the water hygiene risk assessment in place. Actions had been identified, and records showed no action had been taken. Cold water temperatures were not being taken. The provider did not know which hot water outlets were serviced by a thermostatic mixing valve (TMV). Temperatures recorded for outlets previously identified by the provider as having TMV’s, were recorded above the required temperature. Staff did not act to rectify this shortfall or raise concerns with the provider. Records for temperatures of hot food and fridges and freezers showed these temperatures were not always taken and recorded. This placed people at risk of harm from exposure to potential dangers within the environment. However, equipment such as hoists, were regularly checked.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The provider did not have a system in place to determine staffing levels in relation to people’s needs. Following our feedback, the provider implemented a system which indicated that there were sufficient staff to meet people’s needs safely. However, the provider also advised that staffing levels had been increased.

Staff were not always recruited safely. We found gaps in employment history were not always identified and references did not always include employment dates. These omissions were not always identified and addressed by the provider. Regular supervision and checks to assess staff’s competency in relation to moving and handling and medicines management, were not in place. This meant there was a risk people may not receive safe and consistent support that met their needs. However, staff had received training appropriate for their job roles.

The provider assessed and managed the risk of infection.

People were protected from the risk of avoidable infections. Staff had received infection prevention and control training and had access to personal protective equipment. This meant they knew the importance of working hygienically and using personal protective equipment to keep people and themselves safe. Hand hygiene competency checks had been completed. We observed the home to be clean.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Although medicines were stored securely and people received their medicines as prescribed, some aspects of medicines management required further improvement.

We found medicines fridge temperature records did not include daily minimum and maximum readings in line with the provider’s medicines policy. This meant the provider could not be assured the fridge was operating within safe temperature ranges or that medicines were stored safely.

We found records of medicines returned to the pharmacy for disposal were incomplete or missing and not maintained in line with the provider’s policy. This meant the home did not have oversight of the medicines they held and what was returned to the pharmacy.

Medicines records showed regular checks were carried out; however, balances were not always accurate. For example, 1 item was recorded as in stock despite having been returned to the pharmacy. We also found errors had been crossed out rather, than clearly amended in line with the provider’s policy.

‘As required’ medicines were supported by protocols to guide safe administration, and topical medicines, such as creams and gels, were supported by body maps to guide staff on the correct site of application.