Serene Residential Care Limited

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• 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 inspection this key question was rated as requires improvement. At this assessment the rating remains requires improvement. We reviewed 3 quality statements. The provider failed to ensure the management team understood how to deliver safe, care, treatment and support. We identified a breach of regulation in relation to good governance.

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider failed to ensure the management team understood how to deliver safe, care, treatment and support. They lacked the skills and knowledge to lead effectively. The management team was new and the manager lacked experience for the role they were in. There was some support 1 or 2 days a week from a management consultant, who had experience of driving improvement previously at this care home. Staff felt supported and said the management team were approachable. They were confident to raise concerns and felt these would be acted upon.

Whilst the consultant made supportive visits and had a good understanding of the strengths and weaknesses in the service, these visits were not documented so it was not possible to see how the support was structured and measured, or to monitor progress. The provider had limited involvement and there was no evidence of provider visits to assure quality and oversight.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Some risk assessments had been reviewed by clerical staff, but there was no evidence they had the skills necessary to perform this task. Staff told us the manager checked their work and did spot checks, although they were less clear about supervision and appraisal support they could expect to receive.

There was insufficient quality oversight from the provider, and no evidence of any provider visits or quality assurance. There was only limited overview of risks to people in the service. There were no clearly defined responsibilities, roles, systems of accountability or good governance. The provider failed to manage and deliver good quality, sustainable care, treatment and support. There was a failure to act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. There was no evidence of audits prior to January 2024. Since January 2024, there were some basic quality checks, such as the management walkarounds and medicines audits, but no evidence of robust governance systems or thorough checks of quality and safety. Where issues had been identified through the basic audits and checks, there were some actions noted and addressed. Some spot checks of staff practice were completed. An action plan was developed with the local authority and the management consultant, although this had not been embedded at the time of this assessment. This was a breach of regulation relating to good governance as there was no evidence to demonstrate robust oversight of the service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

There was a lack of understanding of how to ensure continuous learning, innovation and improvement across the organisation and the local system. The management team lacked the skills and ability to deliver equality of experience, outcomes and quality of life for people. There was no evidence of the service having learned from accidents/incidents, or measures put in place to identify opportunities for learning. The management team were keen to make improvements in the home and learn from any best practice guidance moving forward, although they lacked the skills, knowledge and experience to identify opportunities for learning.