Your Serenity Limited, Room 6

Updated 13 November 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

This inspection was carried out by one inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

This service is a domiciliary care agency, providing personal care to people living in their own homes.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. The registered manager was also the nominated individual and the proprietor of the service. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

Notice of inspection

We gave the service 48 hours’ notice of the inspection. This was because it is a small service and we needed to be sure that the registered manager would be in the office to support the inspection. Inspection activity started on 14 October 2021 and ended on 29 October 2021. We visited the site office on 14 October 2021.

What we did before the inspection

We reviewed other information we had received about the service, including notifications received from the provider. The law requires providers to send us notifications about certain events that happen during the running of a service. We sought feedback from the local authority, community professionals who work with the service and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We reviewed the provider’s website. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with nine people who used the service and three relatives about their experience of the care provided. We spoke with the registered manager, needs assessor and nine staff. We reviewed a range of records. This included five people’s care records, medication records and daily notes. We looked at five staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service were reviewed, including the provider’s policies, procedures and quality assurance audits.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with three community professionals who engaged with the service

Updated 13 November 2021

About the service

Your Serenity Limited, Room 6 is a domiciliary care agency providing care and support to people living in their own homes. It provides a service to older adults, people living with dementia and people living with a physical disability. Not everyone who uses the service receives personal care. CQC only inspects where people receive personal support with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided. At the time of the inspection the service was providing personal care to 18 people living in the Newbury, Thatcham and surrounding areas.

People’s experience of using this service and what we found

People experienced excellent continuity and consistency of care from designated staff who made them feel safe. Staff had completed safeguarding training and knew how to recognise and report abuse. Risks to people were identified and managed safely. The registered manager ensured enough suitable staff were deployed to meet people’s needs. Staff underwent a robust recruitment process, which explored and confirmed their suitability to support people in their own homes. People received their medicines safely from staff, in accordance with recognised guidance. People and staff consistently praised the registered manager for keeping them fully informed regarding changes in government guidance relating to infection control during the pandemic. Lessons from accidents and incidents were used to drive continuous improvements in the service.

Staff assessed all aspects of people’s physical, emotional and social needs and delivered support wo ensure these were met to consistently achieve good outcomes for them. The registered manager effectively operated a system of spot checks, supervision, appraisal and staff meetings, which supported staff to deliver care based on best practice. Staff emphasised the importance of eating and drinking well and reflected best practice in how they supported people to maintain a healthy balanced diet. Staff worked in partnership with healthcare professionals to make sure care and treatment met people’s changing needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People experienced caring relationships where staff treated them with kindness and compassion in their day-to-day care. People were supported to make decisions about their care and these choices were respected by staff. Staff encouraged people to maintain and develop their independence, and to direct their own health and care whenever possible.

People were placed at the heart of the service and experienced individualised care, which was responsive to their needs and reflected their choices, preferences and wishes. Staff felt valued and well supported by the registered manager who had created an open and honest culture, which reflected in the approach of the staff. Staff spoke passionately about the people they supported and strove to achieve good outcomes for them. At the time of inspection, the service was not supporting anyone with end of life care. When the service had supported people at the end of their life, they had received extremely compassionate care, which respected their wishes to remain at home and ensured they experienced a comfortable, dignified and pain-free death.

The service was well organised and well managed. People, staff and professionals described the registered manager as an inspirational manager. The registered manager understood their responsibilities to inform people when things went wrong and the importance of conducting thorough investigations to identify lessons learnt to prevent reoccurrences. The governance structure of the service ensured there were robust measures to monitor quality and safety of the service. Quality assurance was embedded within the culture and running of the service, to drive continuous improvement. The registered manager had developed effective partnerships to ensure people experienced the best possible outcomes.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 2 March 2020).

Why we inspected

We undertook this inspection as part of a random selection of services rated good and outstanding, to test the reliability of our new monitoring approach.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.