Date of assessment: 4 October 20024 to 22 October 2024. Serene Healthcare Group Ltd is a domiciliary care agency providing the regulated activity personal care. At the time of our assessment there were 38 people using the service. We undertook an announced on-site assessment on the 4 October 2024. We undertook this assessment to ensure the provider had addressed the breaches in regulation previously identified. Improvements had been made to the service, which meant there was no longer a breach of regulation. Focus had been given to improving risk management and the auditing systems of the service. This meant leaders were better at identifying and addressing shortfalls. They were clear action plans, with dates to ensure compliance. These were ongoing and incorporated learning by leaders and the staff team. Staff were recruited safely and there were enough staff to cover existing care packages. Staff received regular training and were well supported. There were systems to ensure effective infection prevention and control measures and the safe administration of medicines. Leaders promoted a learning culture and had a clear vision of the service. This was shared and adopted by staff, and people’s rights including respect, dignity and independence were promoted. Risks people faced had been identified, and actions taken to enhance safety. However, care planning did not provide staff with clear guidance about how to support any distressed behaviour. Some records regarding risk management also lacked detail. The provider was aware of these issues and was taking action to address them.
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Serene Healthcare Group Office, a small domiciliary care agency, was rated Requires Improvement overall on its first inspection, with breaches of Regulation 12 (safe care and treatment) and Regulation 17 (good governance) identified due to unsafe medicines management, inadequate risk guidance, gaps in staff moving and handling training, and ineffective governance audits. Caring, effective and responsive practice was rated Good, with staff praised for kindness, strong end-of-life care, and person-centred approaches.
Concerns (10)
criticalMedication management: “We found multiple gaps in recording on people's medicines administration records (MAR). The registered manager had not investigated these gaps so was not able to assure themselves people had been given their medicines as prescribed.”
criticalMedication management: “1 person was administered their medicine every other day but their MAR instruction said it was to be given daily. The registered manager was not sure what the prescribing instruction should be.”
criticalCare planning: “For a person who was at risk of falls we found they did not have a risk management plan. This meant staff had no guidance on what to do to reduce the risk of the person falling.”
criticalStaff training: “Some staff had not received practical moving and handling training. Whilst they had been provided with e-learning training they had not been shown how to move people safely. They had also not been assessed as competent.”
criticalGovernance: “Governance systems were not effective in identifying improvement needed. For example, the provider had carried out audits of medicines, but not recorded checks on people's medicines records.”
moderateCare planning: “Records were conflicting as they recorded the person's skin was intact but also the person's skin had a pressure ulcer. Guidance was for staff to re-position them regularly. It was not clear what regularly meant.”
moderateStaff competency: “We found 2 members of staff were working with 1 person who needed re-positioning regularly. The registered manager and provider told us these staff had been shown techniques and would have the training needed following our inspection.”
moderateGovernance: “The provider's policies and procedures had not been updated to reflect the electronic recording systems. This meant procedures for staff to follow were out of date and not relevant to the systems in use.”
moderateRecord keeping: “Care plan audits were carried out but did not identify which care plans had been checked. This meant actions identified were not specific to which care plan was needing the improvement.”
minorComplaints handling: “The complaints policy directed people to share their complaint with CQC. This was misleading for people as CQC do not investigate individual complaints. The details for the Local Government Ombudsman were not on the policy.”
Strengths
· No missed calls reported; adequate staffing levels maintained with safe recruitment practices including DBS checks.
· Staff were caring, kind and competent; relatives praised staff highly including comments such as 'Absolutely amazing, I cannot fault them, they are so lovely, really kind and caring'.
· Effective incident and accident recording with lessons shared at staff meetings to prevent recurrence.
· Strong end-of-life care provision; provider and registered manager are registered nurses with hospice experience and received many compliments.
· Good induction process including Care Certificate, shadowing with registered manager, and regular supervisions and appraisals.
Quality-Statement breakdown (24)
safe: Using medicines safelyRequires improvement
safe: Assessing risk, safety monitoring and managementRequires improvement
safe: Staffing and recruitmentGood
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; respecting equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to ensure people have choice and control and to meet their needs and preferencesGood
responsive: Meeting people's communication needsGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Continuous learning and improving careRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empoweringGood
well-led: How the provider understands and acts on the duty of candourGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsGood
well-led: Engaging and involving people using the service, the public and staffGood