Archived: Serene Residential Care Limited

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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The provider was in legal breach of regulations in relation to safe care and treatment, safe management of medicines, safeguarding people from harm or abuse, safe staffing.

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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt.

There was no evidence of an embedded culture of learning from reportable safety events. Accidents, incidents, safeguarding concerns and falls were not subject to effective investigation or analysis. There was no evidence that trends, patterns, or repeated concerns were identified or acted upon. As a result, no meaningful action had been taken to reduce the likelihood of reoccurrence, demonstrating a failure to promote a culture of continuous improvement and learning from events that could, or did, compromise people’s safety.

Potential risks to people were not consistently identified or addressed. There were no appropriate risk assessments for some people, even where known risks were present. This failure to act on known concerns placed individuals at increased risk of avoidable harm.

In addition, the service lacked a clear and effective system for the management of complaints. While some staff had recorded complaints raised by people using the service, there was no oversight or governance process in place to ensure these were reviewed, escalated, or responded to by service leaders. There was no documented evidence of investigations, outcomes, or actions taken in response to complaints. This meant concerns raised by people were not taken seriously or used as opportunities for learning and service improvement.

Overall, the provider failed to demonstrate a proactive or responsive approach to safety, incident management, and complaints. The absence of systems to learn from adverse events or feedback meant lessons were not learned and improvements were not made, exposing people to ongoing risk and undermining confidence in the safety and responsiveness of the service.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Admissions into the service were not consistently managed within a safe and structured framework, nor aligned with established best practice standards. The service lacked a systematic and robust process for assessing individuals’ current needs to ensure that placement decisions were appropriate and safe. Some people reported that they were admitted to the service without undergoing a formal assessment or consultation. There were no effective pre-admission processes and risk-informed assessments to guide decision-making. As a result, people were admitted without sufficient evaluation of whether the service could meet their needs. The failure to ensure safe or appropriate admission to the service created a risk to people’s safety, wellbeing and outcomes.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Systems and processes intended to safeguard people from the risk of abuse and neglect were either not in place or not operating effectively. Staff did not demonstrate the necessary awareness or responsiveness to indicators of abuse, thereby failing to uphold their statutory duty to protect people from harm. For example, 1 person was observed to be verbally abusive to another person in the service, but staff did not identify or act upon these behavioural signs which were indicative of potential safeguarding concerns. Safeguarding referrals were not always made, and there was a lack of timely and protective response to individuals at risk of harm or neglect.

People’s personal care was being neglected. Records showed only 8 out of 25 people had a documented shower during the month of April, suggesting a systemic failure to meet basic care needs.

Furthermore, 1 person who had been identified as being at heightened risk of self-harm had no safeguarding measures or risk management plans in place to mitigate this risk. This represents a serious failure to implement protective systems, placing individuals at continued risk of avoidable harm.

As a result of these concerns, safeguarding referrals were submitted by the Commission, for multiple individuals, following the site visits.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks to people using the service were not being appropriately identified, assessed, or managed, placing people at risk of avoidable harm. Risk assessments were either absent, incomplete, or not adhered to in practice, and individuals were not meaningfully involved in planning to manage risks related to their care and support. For example, there were no risk assessments in place for some people who had known and either previous or ongoing risks, which may impact on the safety of themselves and others. The absence of a structured risk management plan failed to ensure appropriate safeguards were considered or implemented.

In addition, there were significant failings in the care and risk management of people with diabetes. Of 4 people we reviewed with diabetes, only 2 had care plans in place, and none received dietary support aligned with clinical needs. One person had a recorded blood glucose level considerably higher than their stated normal range but was still offered foods high in sugar such as cakes, biscuits, swiss rolls, and crisps. This demonstrated a lack of safe clinical oversight, and failure to mitigate known health risks.

Falls risks were also poorly managed. One person experienced 4 falls within a short timeframe. Despite these repeated incidents, there was no review or update to their risk assessment or care plan, and no evidence of mitigation strategies being implemented to reduce further harm.

Relatives told us they were not sure whether their loved ones were safe in the service as they were “unaware of what safety measures were in place despite [relative] being known to have falls or try to abscond.” Further to this many people we spoke with confirmed they did not feel safe in the service.

The lack of effective risk management processes, combined with the failure to involve people in planning their care, resulted in unsafe practices that compromised people’s health, wellbeing, and dignity.

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

The environment was not consistently maintained in a manner that promoted safety, security, and dignity for individuals using the service. Personal Emergency Evacuation Plans (PEEPs) had been completed; however, they lacked essential information such as room numbers. This omission could impede an effective emergency response during a fire or other critical incident, putting people at risk.

Despite requests, the provider was unable to supply evidence of completed fire drills or evacuation procedures. This raised further concerns regarding the preparedness of the service to respond safely in the event of an emergency.

There were significant safety concerns in the environment. We observed some fire doors were propped open using ‘wet floor’ signs and chairs, compromising their effectiveness in the event of a fire. In addition, 1 fire door did not close properly. Although this was rectified during the inspection, it was only addressed after being pointed out by inspectors, indicating a lack of proactive maintenance and safety oversight.

While some dementia-friendly adaptations such as signage were in place, there were limited environmental adaptations to support orientation or accessibility for people living with cognitive impairment or other support needs.

The premises were not secure enough to prevent unauthorised access to the home or individual people’s rooms. On the second day of inspection, inspectors were able to enter the building through an unlocked front door without being challenged or noticed by staff. People told us they did not always feel safe and expressed concerns about the security of their personal belongings. One person commented, “There are locks on the doors, but people still get into my room as there is a groove in the lock on the outside.”

These findings demonstrate a failure to maintain a safe, clean, and secure environment, directly impacting people’s sense of safety, dignity, and wellbeing.

The provider did not 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 work together well to provide safe care that met people’s individual needs.

Staff deployment was not safe or effective. There were extended periods during which no staff were present in communal areas, resulting in a lack of supervision and support for people using the service. This was echoed in feedback from relatives and people using the service. One relative told us, “[Person] was attacked in the lounge by another resident, there was no staff around, so I had to report this.” People also reported a frequent lack of staff presence, particularly on the ground floor. One person commented, “There is not enough staff downstairs, and when visitors come there is not normally any staff on the ground floor.” The lack of visible staff presence increased the risk of harm and meant that people could not always access help or feel safe in their environment.

There was also a lack of robust oversight in relation to staff training and competency. There were no training records to evidence staff compliance with mandatory and role-specific training. Records showed that 3 staff members had not completed any training but were working in care roles and were included in the staffing numbers. These staff were actively responsible for providing care without having demonstrated the necessary competencies.

Furthermore, staff had not received training aligned with the assessed needs of people living in the service. No staff had completed training in mental health, despite caring for individuals with mental health needs. This lack of targeted training meant that staff were not adequately equipped to provide safe and effective support to all individuals.

We also reviewed 3 staff recruitment files and found the provider had not always followed safe recruitment processes. For 1 staff member in a leadership role there was no evidence of training or qualification checks having been completed prior to the individual commencing in post. The staff member had not completed any mandatory or role-specific training before assuming responsibility for leading the service. All of this directly conflicted with the requirements set out in the provider’s own recruitment policy.

The provider did not adequately assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The service had an up-to-date infection prevention and control (IPC) policy, and routine IPC audits had been completed, with documentation indicating compliance with the provider’s IPC procedures. Cleaning schedules were also in place, reflecting a planned approach to maintaining hygiene standards. However, observations made during the inspection did not align with the records reviewed, indicating a significant gap between documented procedures and actual practice.

Staff wore personal protective equipment (PPE) appropriately during mealtimes, but there were multiple and widespread shortfalls in the implementation of safe IPC practices. For example, on the first day of inspection, hand sanitiser dispensers on the first floor were empty, clinical waste bins were not present in toilet areas, and there was only 1 functioning sluice on the first floor for the disposal of waste and for the safe removal of PPE. This limited the service’s ability to effectively control the risk of cross-contamination.

Hand hygiene facilities were inadequate across the service. Inspectors observed multiple bathrooms without access to handwash or paper towels, limiting the ability of both staff and people using the service to maintain effective hand hygiene.

Despite completed cleaning schedules, we found communal toilets on the ground floor to be visibly unclean, and there were malodours present in several areas of the service. Inspectors also noted concerns about cleanliness and hygiene. While some individuals had personalised their rooms, the overall standard of cleanliness throughout the service was poor. In several instances, bedding was found to be soiled or not changed regularly, failing to uphold basic standards of hygiene and comfort.

Some improvements were noted on the second day of the inspection, specifically in relation to the reduction of malodours and improved availability of some hand hygiene provisions.

Medicines were not always managed in a safe or consistent manner, and there were significant shortfalls in the implementation of effective medicines optimisation practices. Although medicines were mostly stored securely and routine storage temperature checks were being completed, there were broader systemic issues identified in the management of medicines.

Protocols for the administration of ‘as required’ (PRN) medication were out of date and had not been reviewed in line with best practice or clinical guidance. This meant staff did not have access to current, individualised guidance for the safe and appropriate administration of PRN medicines, increasing the risk of inconsistent or inappropriate use.

The provider could not demonstrate that people were having their medicine patches applied properly or rotated as necessary to safeguard their skin and prevent overdose. Records relating to the application of topical creams were inconsistently completed. This meant we could not be assured people’s creams were applied as directed. Additionally, creams were stored in bedrooms without individual risk assessments in place to ensure safe and appropriate storage. This presented a potential risk of misuse, contamination, or unintentional access by others.

These failings in the safe use and administration of medicines placed individuals at risk of not receiving their medicines as prescribed and undermined the principles of medicines optimisation, which are intended to ensure the right person receives the right medicine at the right time and in the right way to achieve the best possible outcomes.