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 inspection we rated this key question good. At this assessment, the rating has changed to requires improvement. We reviewed 4 quality statements. There were insufficient staff to meet people’s needs at all times and not all staff received training to enable them to keep people safe. The provider did not have an effective safeguarding process in place. The environment was clean, but evidence of maintenance checks was not provided. We identified 4 breaches of regulation in relation to safe care and treatment, safeguarding people from abuse, staffing and the safe recruitment of staff.

This service scored 62 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

Most people told us they felt safe in the service. Comments included, "I absolutely feel safe here" and "I think my relative is safe here.” However, one relative said their loved one referred to a specific event and felt staff had not kept their relative safe enough.

Not all staff were clear about safeguarding procedures. The provider failed to work with people to understand what being safe meant to them as well as organisational partners. The management team showed little understanding about protecting people from the risk of abuse.

One person was not protected from harm as they could not reach their call bell in an emergency. Some staff struggled to understand spoken English, which meant people were not always safeguarded from the risk of harm. We saw staff supported people to move safely around the home.

There were insufficient systems to protect 1 person who had been exposed to multiple safeguarding incidents. Safeguarding events had not been monitored and reviewed to ensure safe outcomes. The management team had not identified these events before our assessment. Best interest decisions were not in place where people lacked capacity. The nominated individual did not have any oversight around people's safety. This was a breach of regulation relating to safeguarding people from abuse.

Risk assessments were found to be significantly lacking in important detail or had not been completed. Specific examples were identified around risk assessments needed for people who were smokers, living with epilepsy and diabetes. Safeguarding risks had not been incorporated into relevant risk assessments. This was a breach of the regulation relating to safe care and treatment.

Some painting and decorating was being undertaken during the inspection, which could have been more carefully planned as there was wet paint in the areas where people were walking, which meant people were at risk. We observed the deputy manager walking around the home and carrying out safety checks regarding the living environment. The service was clean and tidy. All the equipment we saw in the service, including the laundry and kitchen, was in good working order.

Information from the provider showed regular maintenance checks were carried out. However, there were no records of daily checks of specific areas within the premises and no documentation to support the checklist. During the inspection, the provider was unable to provide evidence to assure us that key building safety checks relating to lifting equipment, electrics, gas, water and fire were up-to-date. Following our inspection, the provider responded and sent us these certificates which showed cover was in place at the time we carried out this assessment.

One person remarked on staff not being settled in their roles and difficulties with language needs. Another person said they missed having staff to talk to. A relative said the residents struggled to understand staff who had English as a second language and also commented on staff leaving soon after starting.

Staff were not always available in the lounge area. There were no staff in the upstairs lounge when some people were eating their lunch in there. One person started to cough during their meal and appeared to need assistance. Another person was unable to reach their meal comfortably, so stopped trying. We observed several occasions when no staff were available in lounge and staff spent a lot of time washing up in the small kitchen. Some staff with English as an additional language lacked understanding of spoken English, which was a barrier to safe care.

The provider did not always ensure adequate qualified, skilled and experienced staff were in place, to effectively provide safe care. Staffing levels were not adequate at all times, particularly where risks may have been present with one person. This was a breach of regulation relating to staffing. We found concerns around recruitment processes for some staff whose files we sampled. Records relating to interviews, job descriptions, induction processes were incomplete and DBS checks were dated after staff commenced their employment. Where external workers entered the home, there was no evidence of any background checks made or close supervision. This was a breach of regulation as the provider did not demonstrate robust recruitment checks had been carried out.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.