Serene Healthcare Group Office Also known as Main Office

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 requires improvement. At this assessment the rating has changed to good.

We reviewed 7 quality statements for this key question. Improvements had been made to management oversight and overall governance of the service. This had included the introduction of a clear quality auditing system with various action plans for any identified areas of development. The action plans were regularly monitored and included dates of compliance. However, shortfalls with care planning found at this inspection had not been identified. Leaders were very much part of the service on a day-to-day basis. They had strong values and enabled a supportive culture by listening and working with staff. Leaders promoted their own learning and that of others and expected ongoing development of the service. People being in receipt of a safe and effective service which met their needs, was an expected outcome of leaders. There were systems to promote equality and diversity.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders demonstrated strong values and a desire to ensure people’s rights were promoted. They told us they regularly spoke to staff and facilitated workshops to ensure a clear understanding of the vision and culture of the service. Staff told us there was a supportive culture. They said they enjoyed their role and had developed good relationships with people and each other.

There were systems to ensure the vison and expected culture of the service were being implemented. This included care reviews and leaders phoning people to gain feedback. Spot checks of staff performance gave people further opportunities to share their views. Values and visions of the service were shared with staff through discussions and training.

Staff gave positive feedback about leaders, although some inconsistency of approach between members of the management team was raised. Leaders told us they would consider this and take appropriate action as required. Other feedback included describing leaders as ‘friendly’ and ‘supportive’. One staff member told us they felt comfortable when engaging with leaders. Leaders told us they aimed to be supportive and kept staff well-informed about the service and its development. They said they ensured staff who had arrived in this country to work at the service, were met at the airport and were helped to settle in and be part of their local community.

Leaders were very visible and involved in the service on a day-to-day basis. They had developed effective systems to ensure staff were well-supported. This included a detailed induction, staff meetings, regular one to one meetings with leaders and informal discussions about people’s needs.

Leaders told us they had an open culture and encouraged staff to raise anything of concern or in need of development. They said anything raised would be promptly investigated and resolved accordingly. Staff confirmed this. They said they were confident to speak up and knew they would be listened to and taken seriously.

There were systems to encourage people and staff to share their views about the service. This included phone calls, meetings and satisfaction surveys. The surveys demonstrated leaders were good at listening and responding to concerns. There was a speaking up policy for staff to access, and people were provided with a copy of the complaints procedure when first introduced to the service.

Leaders and staff told us the team was very supportive of equality, diversity and inclusion. They said this enabled a diverse team which consisted of a wide range of nationalities, ages and experiences. Staff told us they had completed equality and diversity training.

Systems promoted workforce equality. There was an equality and diversity policy, and associated training formed part of the provider’s mandatory training programme. There was a supportive culture and diversity was celebrated. Leaders held a Sponsorship Licence, which is a government initiative which enables employers to employ overseas skilled workers. Leaders told us the scheme was working well and enabled a diverse workforce.

Leaders told us they had significantly developed the agency’s quality assurance systems. They said this had enabled more effective monitoring and the prompt identification of any areas in need of development. Leaders told us they undertook spot checks of staff performance, and there were checks of systems such as medicines, infection prevention and control and staff recruitment and training. Staff confirmed the spot checks of their performance were unannounced.

Following the last inspection, improvements had been made to management oversight and governance. This had included implementing an improved quality auditing system, with additional areas of service provision to be assessed. Records showed the checks had been completed at the required frequency and there were action plans to address any shortfalls identified. These were discussed with staff and action was being taken in a timely manner. Spot checks of staff performance were regularly undertaken, and staff received formal one to one meetings with their line manager. This enabled learning and a development of practice. However, whilst improvements to auditing had been made, not all shortfalls were being identified. This included the lack of detailed information within some care records found during this inspection. Leaders told us these areas would be added to an action plan and consideration would be given to the best way to address them. They anticipated this would include the implementation of a range of workshops and training courses to ensure consistent improvement throughout the staff team.

People told us staff liaised with relevant healthcare professionals as needed. This included informing professionals, such as the person’s GP, of any ill health or the need for a repeat prescription. People said staff were good at liaising with their relatives. One relative said staff learnt effectively from them, which helped meet the person’s needs more effectively.

Leaders told us they had developed links with various health and social care professionals in the area. This had included local GP surgeries and the local authority. Staff confirmed this. They said if they were concerned about a person, they would gain consent for their relatives, GP or the NHS out of hours service, to be contacted for advice.

Health and social care professionals did not raise any concerns in relation to partnerships and communities.

People’s care records demonstrated partnership working. This included involving others in the initial assessment of the person’s needs and thereafter within care reviews. Documentation seen during this assessment demonstrated relatives and health care professionals were informed of any identified concerns involving the person’s wellbeing.

Leaders told us learning and ongoing improvement of the service was important to them. They said they had recognised, when setting up the service, they had taken on too much too quickly. This had caused various challenges, and the service was not performing as they wanted it to. In response to this, leaders told us they had taken the service ‘right back to basics.’ They said this had enabled a sound foundation to work from, and they were now making good progress. Leaders told us they were keen to continue learning and would ensure ongoing development of the service. This included the possibility of widening the scope of the service to support people with very complex or nursing needs. Following the inspection, leaders applied to CQC to be registered to provide this type of service. The application has since been agreed.

Leaders worked closely together to ensure the future development of the service. They said they had regular meetings but discussed different aspects of service provision informally throughout the day. Leaders had daily contact with staff to ensure learning and development. This was through informal discussions, meetings, workshops and training. There were systems such as telephone calls to people and review meetings to gain feedback about the service. Any concerns were discussed and feedback contributed to the ongoing development of the service.