Archived: Serene Residential Care Limited

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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The provider is in breach of legal regulations in relation to good governance of the service and employment of fit and proper persons.

This service scored 32 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Staff feedback revealed concerns about the culture and direction within the service. Staff were unable to clearly articulate the provider’s vision, values, or expectations. The workforce did not demonstrate the skills, knowledge, or culture associated with a competent and cohesive care team.

Staff reported an inconsistent management team which had contributed to a consistent lack of guidance and support for staff in the service.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leadership within the service had not been consistent, and oversight at all levels of management was ineffective. The provider could not demonstrate managers and leaders had the skills or competence necessary to lead the service safely and effectively and did not provide direct supervision for them. The provider had not followed their own recruitment policy in the recruitment of the manager, and we identified multiple areas of shortfalls in this process.

The provider had not ensured that appropriate support, supervision, or development opportunities were in place for those in leadership roles. As a result, quality assurance processes were not completed effectively or accurately and failed to provide any meaningful resource as a way of driving improvements in the service.

However, following the feedback provided during the inspection the provider took action and made changes to the leadership in the service. These changes were being developed further.

People did not feel they could speak up and that their voice would be heard

We saw no evidence of staff meetings taking place and being documented for 6 months prior to the inspection. An analysis of staff surveys was completed in October 2024 which showed a brief collation of answers given to questions but there had been no response or outcome to the perceived lack of action mentioned by staff when they reported concerns. This was also identified as a shortfall whereby staff had recorded complaints made to them by people, but these were not addressed by leaders or managers. Some staff told us the previous manager was supportive but since the recent changes they felt they did not get support or time with the manager to report any concerns.

Following both days of inspection a staff meeting was held and minutes provided which demonstrated how the leaders had shared feedback from the inspection to staff. However, there was no staff interaction recorded in the meeting minutes to show how staff had contributed to the discussion.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Recruitment records demonstrated equitable and fair recruitment practices, and the provider had an up-to-date recruitment policy. However, the provider did not recruit a diverse workforce which reflected the needs and backgrounds of people in the service. For example, all staff were from an ethnic minority background, however most people in the service were of white British heritage. One person reported, “I can’t have a conversation with staff as they just don’t understand me, and I don’t understand them.”

There was no evidence of any other strategies implemented in the service to promote fair and equitable treatment of staff.

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.

Governance systems and quality assurance frameworks were not operating effectively. Where audits had been undertaken, they failed to identify the significant shortfalls and systemic failings found during the inspection. For example, the manager’s audit had been completed in January and February 2025. Information was inaccurate in several areas. For example, personal emergency evacuation plans (PEEPs) were in place for people in the service, but these omitted vital information such as room numbers for all people in the service. Fire evacuation drills were not documented as completed routinely; medication audits showed high compliance.

Key governance areas were either absent or inadequately developed, including oversight of weight and nutritional management, staff training compliance, day-to-day operational management and the accuracy and completeness of care plans and risk assessments. Furthermore, there was no provider audit or evidence of oversight of the management of the service. This meant governance systems were not robust and failed to mitigate potential risks and shortfalls.

This absence of structured oversight reflected a lack of strategic leadership and accountability.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Residents’ meetings had not been held, relatives’ meetings had not been held, and we saw no evidence of staff meetings being held. Some records identified professional visits by GPs and district nurses, however, for some people records showed involvement of some specialist professionals had not always been sought in a timely way, such as referrals to mental health teams. We saw a lack of partnership working with professionals prior to new admissions into the service, which meant vital information held by social workers and other professional bodies was not sought before arrival.

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

There was no evidence of an open and transparent culture that supports learning when things go wrong. The provider failed to demonstrate learning from the findings of previous inspections.

The provider did not have evidence of any effective strategies in place relating to driving improvements which focus on improving equity, outcomes and quality of life. The current systems and processes in place around quality assurance were not being effectively implemented, completed or reviewed. There was no evidence of service wide learning from safety events or incidents, and the provider was not enrolled on any innovative research programmes.

Additionally, during this inspection, the provider did not offer evidence of meaningful action or a response plan to address the current concerns identified. This lack of engagement and responsiveness did not provide assurance that the service has the capacity or commitment to implement and embed improvements.