Seraphim Home Care

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 good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care. The service was in breach of the legal regulations in relation to good governance, statement of purpose, fees, display of ratings and notification of other incidents.

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 service had a mission statement with the aims and objectives of the service. The service also had agreed value statements. However, these were not widely shared, known by staff or embedded in the service processes and delivery. People shared positive experiences about how care was delivered. One person said, “The carers are very good.” Another person said, “The ones [staff] I have now are very good at personal care and leaving me set up with everything I need.” A relative said, “Not everything is perfect yet, but the carers are now all really friendly.”

The service did not have leaders at all levels who understood the context in which they delivered care and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the knowledge and systems to effectively lead the service.

People and staff told us they could speak up. However, the systems at the service did not support a culture of speaking up or ensure effective actions were taken in response to concerns raised. The local government and social care ombudsman had directed the service to make an apology by a specific date in 1 case. This had not been completed and no actions had been taken to prevent the same concern happening again.

The service had a diverse workforce. Staff skills were not always developed so they gained experience in how to support people with their individual needs. However, flexible working was arranged for staff, to support them with their personal responsibilities and commitments and that valued them individually. Recognition of positive staff contributions was starting to be acknowledged but formal processes were limited.

The service did not have clear staff roles and good governance. There was a lack of provider oversight and no governance systems to ensure high quality safe care. The service did not have an improvement plan to ensure areas previously identified were actioned. The providers website and key documents were not reviewed regularly. For example, the statement of purpose and organisational policies and procedures. Quality and safety checks in these documents were not completed. Policies and procedures were accessible for staff. Feedback sought from people in August 2024 had not been analysed or summarised. This meant actions taken were unclear and people did not receive an outcome to their feedback. The provider had shortfalls in reviewing staff training. Staff had not received mandatory training as described in the providers documents or training in areas specific to people’s needs. For example, food hygiene and catheter care. There was a lack of training and development for senior staff. A manager had not been registered with CQC as a condition of the providers registration since October 2023. The service did not have an effective system to ensure accidents, incidents or safeguarding concerns were reviewed and notified to the commission as required. We found 2 allegations of abuse reported to the local authority but not notified to CQC as required. The providers CQC assessment rating had not been displayed on their website or at the location as legally required. The providers statement of purpose was not accurate or had been submitted to CQC with changes as required since 2019. The provider did not have up to date signed documentary evidence of service users’ contracts, fees and terms of service as legally required. For example, the agreed cost of care and support hours being provided. People’s feedback had been sought in reviews and telephone conversations. 1 person said, “In the past 6 months there has been a big improvement, carers are now generally on time.”

The service did not take steps to actively develop partnership working and community networks, to ensure services worked effectively for people. The service did not share information and learning with partners or collaborate in order to drive improvement in providing high quality care to people.

The service did not focus on continuous learning, innovation and improvement across the organisation. The lack of governance meant areas for learning and development were not identified so improvements could be made. Areas for improvement identified by external stakeholders had not been progressed. This was a missed opportunity to drive improvements in the service. Staff told us some learning was shared through internal communication channels. For example, a staff WhatsApp group and team meetings. Team meeting minutes were available for staff to view who had not been able to attend. A staff member said, “We usually get an email with the notes.”