Archived: Serene Residential Care Limited

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The provider is in breach of legal regulation in relation to person centred care and treatment.

This service scored 25 (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 make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Most care plans lacked sufficient person-centred detail to guide staff in delivering safe and appropriate care. Only 7 of the 25 people living at the home had the 'About me' section completed in their care records, to show their personal life stories and what mattered to them. Where care plans had been reviewed, updates were recorded in a fragmented and superficial manner, rather than reflecting a meaningful reassessment of needs with clear, actionable guidance for staff. The information contained in the care plans was contradictory and did not clearly reflect the person’s assessed needs.

We found in several cases essential care plans were either missing or so limited in scope that they provided minimal instruction. For example, some people did not have diabetes care plans, no care plan where 1 person smoked and had nicotine patches, and catheter care plans were not always in place. Medication care plans lacked significant, essential information for people’s specific health needs. All of this compromised staff's ability staff to understand and meet the needs of individuals effectively.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

Some relatives informed us they felt their loved ones received the care and support they required. However, we found shortfalls in the delivery of safe care which aligned with people’s needs. One person told us they had not had their bedding changed since 7 April 2025, which was over 3 weeks, which did not align with their own hygiene standards. No action had been taken to address this. We also found some other people’s bedding was not clean during the inspection and records had failed to demonstrate regular changing and cleaning of these.

There was a lack of understanding from staff of people’s assessed need and several staff we spoke to were unable to explain how people’s medical conditions affected them daily. They could not describe how they were able to support them safely and, in a person, centred way. Staff confirmed they required more training particularly around mental health needs.

We were informed 3 people in the service attended regular day care services. However, there were contradictions in the records of people’s attendance at the services. One person’s records indicated they no longer attended, with no rationale for this. There was no other evidence of people accessing community-based services or activities.

The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service was not compliant with the Accessible Information Standards which requires them to make information available to everyone in ways they can understand. Despite supporting individuals with learning disabilities and dementia, there was little evidence that care-related information had been adapted or made available in accessible formats. Care plans and service information were not provided in alternative formats, limiting the ability of some service users to understand and engage with their care.

People and relatives told us there were no assessments carried out with people or relatives prior to admission. They told us information was passed from the social worker about them or their loved one. Furthermore, when information regarding their loved one had changed relatives told us this was not always communicated with them.

Staff told us updates about people in the service were shared through [digital] messages to their own personal phones. This meant the people’s rights to have their private information protected, were not regarded.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support.

Despite some complaints being made by people in the service, and staff recording these, not all complaints had been responded to or resolved appropriately. Additionally, there was no evidence of a systematic or proactive approach to gathering feedback on the quality of the service. Inspectors requested, but were not provided with, evidence of regular meetings or surveys involving staff, service users, or relatives.

Relatives confirmed they had not been invited to attend any relative meetings in the service. Some people also confirmed they had not had meetings with the management and 1 person told us, “We have requested a meeting with the manager to discuss our concerns, particularly in relation to the low staffing numbers. The meeting was arranged but then never took place and has not been rescheduled.” As a result, the provider could not demonstrate that feedback mechanisms were in place to enable continuous service improvement or inclusive decision-making.

The provider did not make sure that people could access the care, support and treatment they needed when they needed it.

Whilst we did see evidence people were being seen in the service by other professionals, such as district nurses and GPs, there was no record to demonstrate people being able to access appointments and support outside of the service.

Most people who were able to request it gained access to the outside garden areas, however, those with more complex needs were not supported to have access to the same outdoor spaces. They were limited to the first floor communal areas. Furthermore, reasonable adjustments were not in place to allow those with communication difficulties to have access to different processes equally, such as complaints.

The provider did not maintain regular correspondence with people to review their needs and find out if further support was needed. Care plans did not show involvement of people or their representatives in these processes.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

The service did not consistently promote equality or meet the individual needs of all people. Those with protected characteristics, such as dementia, mental health and learning disabilities, under the Equality Act 2010, did not always have their needs accurately identified, documented, or supported. Care plans often failed to reflect these needs, and staff lacked the training and competence necessary to provide culturally competent and inclusive care. We completed observations on people in communal areas during the inspection. People in the lounge during the times our observations were completed were not spoken to; staff did not engage, and people were left and ignored.

People were not always supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

There was no one on end-of-life care at the time of the inspection, however, on reviewing people’s current care plans we found some people did not have end of life care plans in their records, and those who had them did not have any specific detail captured on their preferences. One person’s end of life care plan simply stated, ‘Family are aware of end of life wishes.’ The lack of detail meant when people approached end of life, care staff did not have the guidance on how to provide care and treatment to them in a way which promoted their wishes, preferences and met their health, wellbeing and spiritual needs. Furthermore, the training compliance record showed 5 out of 15 care staff, inclusive of the manager at the time of inspection, had not completed end of life care training. 2 other care staff members were due training in May 2025. This meant 46% of care staff were not trained or up to date in this area of care.