Serene Healthcare Group Office

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

We reviewed 8 quality statements for this key question. There was a learning culture which included learning from any accidents, incidents or any shortfalls found during audits of service provision. Focus had been given to staff training to enhance knowledge, but also to ensure staff had a clear understanding of their responsibilities. Improvements had been made to risk management and information now provided staff with improved guidance to ensure safety. However, work was required to help staff support people with distressed behaviour; the provider was aware of this. There were enough staff to cover existing care packages and people received a reliable service. Staff knew people well and positive relationships had been established. There were systems to prevent and control infection. Improved systems had been introduced to ensure people received their medicines as prescribed, but formats such as body maps were not available on the electronic system. Leaders were aware of this and were considering how to address the shortfall. People received a detailed initial assessment, which enabled a smooth transition to the service. Staff gained advice and worked alongside health care professionals as required.

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.