Serenata Care Ltd Trading as Two Cedars

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 provider leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.
This is the first inspection for this provider. This key question has been rated requires improvement.

This meant the provider management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The provider was in breach of legal regulation in relation to good governance.

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 service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

There was a lack of oversight to ensure people were included in all aspects of their care and support and engaged in a way that was meaningful to them. Staff and people were not provided with opportunities to give feedback or contribute to the running of the home. For example, there were no records of staff meetings. The manager was new to post and worked on an action plan for improvement. The changes made needed time to be embedded in the home’s culture.

Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

The provider had not played an active role in the service during the absence of a registered manager. This meant the provider had failed to consistently identify care provision was not always safe, high quality and in line with regulatory requirements. A new manager had recently been appointed and told us they felt supported by the provider. Staff described the manager as approachable and supportive.

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 report concerns to the manager and they were confident that the manager would take their concerns seriously and address them. Staff told us they were aware they could report any concerns they had externally to the local authority or CQC.

The provider valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff told us they were valued and supported by management. The manager told us due to the recent management changes they have focused on building up the staff teams’ confidence and going forward they planned to implement a staff reward system. An equality and diversity policy was in place and staff completed relevant training.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

There was no effective provider-level oversight within the home. The provider was not carrying out checks, audits, or processes to monitor the quality and safety of care to ensure regulatory compliance. A recently appointed manager had begun working to implement improvements.

Governance systems and processes were either not in place or were not yet embedded into practice. For example, actions identified in the fire risk assessment and water hygiene risk assessment had not been completed. The provider did not have an effective system to ensure recruitment processes were followed. For example, gaps in employment history were not always identified, and references did not consistently include employment dates, or this was not consistently addressed.

There were no systems in place to monitor staff practice or provide supervision. Staff were not receiving regular supervision or competency checks in areas such as moving and assisting and medicines management. The provider had not identified the lack of a systematic approach to staffing, nor that people were not always being supported to access activities, hobbies, and interests. Systems were also not in place to ensure medicines were managed safely or that feedback was regularly sought from people and staff. As a result, people were exposed to avoidable risks of harm.

The provider understood their duty to collaborate and work in partnership, so providers work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff told us they communicated with health and social care professionals as required. An external professional spoke positively about working in partnership with the new manager.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Although there was an action plan in place to drive improvement the provider and manager did not have effective oversight of the service to drive improvements.

Staff meetings did not take place, which meant the provider did not encourage staff to share ideas and there was no reflection of improvements. The manager told us they planned to hold regular staff meetings. Our inspection found widespread shortfalls which were not always identified or addressed through the provider’s quality management systems.