Archived: Serene Residential Care Limited

Updated 23 April 2025

Dates of assessment were from 30 April to 15 May 2025. This was a responsive assessment due to concerns the Care Quality Commission received from the local authority regarding potential risk to people. The service is a care home providing personal care for people, some of whom are living with dementia, have diagnosed mental health conditions or learning disabilities. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

Following an inspection on 15 February 2024 the provider was in breach of 6 regulations in relation to person centred care, safe care and treatment, safeguarding, good governance, safe staffing and fit and proper persons employed. Improvements had not been made, and the provider remained in breach of these regulations. We also found the provider was in breach of the regulation relating to consent to care and treatment at this inspection.

There had been a lack of oversight and management of governance systems since the last inspection. Leadership and management had not been consistent, which meant the provider had failed to drive improvements. People were not safeguarded from abuse, risks to people were not managed safely, staff were not adequately trained, and safe recruitment processes had not always been followed. Medicines were not managed safely. People were not always encouraged to have full control and independence. People were not always treated with dignity and respect, and they did not receive person centred care.

However, we did see some kind interactions from staff to people, and there was some evidence of partnership working with some professionals.

This service is being placed into special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provider a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.

Updated 23 April 2025

Feedback from people and their relatives was mixed. People told us they did not always feel safe and did not feel their belongings were safe in the service. They also told us their personal care was not always met. We observed people had to wait for basic care and support such as being taken to the toilet, and we saw care records showed people were not offered or received support with showering regularly. Some people had dirty bedding, and one person informed us their bedding had not been changed for 3 weeks.

Relatives told us there were issues with the laundry and clothes going missing which were not rectified and where wheelchairs were being used this was not always done safely. One relative informed us footplates were not always safe or secure and had on occasion fallen off when in use and caused bruising to people’s shins.

Activities were not being offered in the service which meant people had long periods of disengagement through the day. One relative told us, “[Person] is very bored. There are no activities going on despite their being an activity list up on the wall. These are not happening.” Another relative confirmed, “They don’t go out, they have no activities. They have done one afternoon tea for [charity] that’s all I have seen. [Relative] is capable of more.”

However, people and relatives did give positive feedback for most of the care staff, stating they felt the best part of living at Serene was the staff who for the most part were reported to be nice and caring.