CQC report explained · a residential care home
What the CQC found at Serenity UK Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found that risks were assessed and reviewed, there were enough staff, recruitment checks were completed and medicines were administered and recorded safely. Repairs and food safety arrangements had also improved.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- The registered manager had increased audits from monthly to weekly and checked that actions were completed. Inspectors found a person-centred culture, regular meetings and cooperation with other professionals.
What inspectors found, May 2023
Serenity UK Limited is rated Good; inspectors found improvements in safety and management since the previous Requires Improvement rating.
This was an unannounced focused inspection on 14 April 2023. One inspector spoke with two people, a staff member, a care manager and the registered manager. They checked four care records, four staff files, the environment, medicines, fire safety and quality checks.
The home was rated Good for Safe and Well-led. Inspectors found that risks were assessed, staff were available, medicines were managed safely and repairs had improved infection control and safety. Staff had suitable checks and training.
The provider had acted on the previous inspection action plan. Weekly audits had replaced monthly audits, and the provider was no longer in breach of Regulations 12 and 17. The overall rating changed from Requires Improvement to Good, but the other three key questions were not inspected during this visit.
Improved safety
The home had repaired earlier environmental problems, improved food storage and put window restrictors in place. Staff also followed food safety procedures.
“At this inspection we found that improvements had been made and the provider was no longer in breach of regulation 12.” from the report
Safe medicines
Trained staff administered medicines. Records were checked, staff competence was assessed and photographs on medicine records helped identify the correct person.
“People's medicines administration record (MAR) charts were accurately filled by staff and regularly checked by the registered manager.” from the report
Regular quality checks
The manager increased the frequency of audits and checked that identified actions were completed.
“Since the last inspection, the registered manager's audits had increased in frequency from monthly to weekly.” from the report
Person-centred support
People were involved in their care planning and supported with goals such as cooking, shopping, cleaning and personal care.
“People were supported to achieve good outcomes. The service was person-centred and focused on supporting people to achieve their individual goals.” from the report
Stable staff team
Most staff had worked at the home for more than three years. Inspectors said this helped staff understand people and notice changes in their mental health needs.
“The service had an established staff team with most in post for over 3 years.” from the report
Limited inspection scope
minorThis visit checked Safe and Well-led only. The report does not provide new findings for Effective, Caring or Responsive, so families should ask about those areas directly.
“This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.” from the report
- 01What were the current ratings and findings for Effective, Caring and Responsive at the previous inspection?
- 02How will you assess and review my relative's risks and update their care records if their mental health needs change?
- 03How often are medicines records and staff medicine competence checked now?
- 04What actions from recent audits remain open, and how will you show that they have been completed?
- 05How will my relative be involved in setting goals, choosing support and reviewing their care?
This was an unannounced focused inspection of Safe and Well-led only; the other ratings carried over from the previous inspection. This explanation was written from the published report of 20 May 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2023
Serenity UK Limited rated Requires Improvement; inspectors found important safety and management problems, including fire and infection risks.
This was an unannounced, focused inspection on 7 September 2022. One inspector observed care, spoke with people, relatives, the registered manager and staff, and checked care, medicine and management records.
The home had problems with cleaning, food storage, broken tiles, an unsafe boiler cupboard, hand-drying facilities and bedroom window restrictors. Fire safety actions had not been completed, and staff were not wearing face coverings in line with government guidance. Inspectors said these issues increased the risk of harm, although they found no evidence that anyone had been harmed.
The home was rated Requires Improvement overall, and for Safe and Well-led. People said they were happy living there. Medicines were managed safely, there were enough staff, and staff understood safeguarding. The registered manager acted on some issues during and after the inspection, but CQC issued a warning notice and requested an action plan.
Medicines
People's medicines were stored securely and managed safely. Inspectors found no recording errors and saw that medicine reviews took place regularly.
“People's medicines were kept securely and staff carried out regular audits to check that medicines were being managed in the right way.” from the report
Staffing and safeguarding
There were enough staff to support people during the day, including with activities and community visits. Staff had safeguarding training and safe recruitment checks were completed.
“The service had enough staff to support people during the day. This included additional support for people's activities and community visits.” from the report
People felt supported
People and relatives said they were happy with the home and felt supported. Staff were described as friendly, and people were encouraged to develop independent living skills.
“People told us they were happy at the service and felt staff supported them well.” from the report
Environmental and infection risks
seriousThe home needed a deep clean. Broken tiles, unsafe storage of cleaning chemicals, poor hand-drying facilities and food hygiene problems created risks to people's safety and health.
“The service was in need of a deep clean and aspects of the environment were not safe.” from the report
Fire safety
seriousProblems identified in a fire risk assessment had not been dealt with. Inspectors were not assured that people could be kept safe in a fire, and they contacted the London fire authority.
“We were not assured by the fire safety measures in place at the time of the inspection.” from the report
Risk management
seriousRoutine checks had failed to identify several safety problems. The provider did not always assess, monitor or improve the safety of the home.
“The registered manager had not recognised and acted upon the environmental and infection control risk at the service.” from the report
Management and reporting
seriousThe provider had not told CQC about certain changes, events and incidents. Staff were also unclear about who the deputy manager was when the registered manager was away.
“Some important information was not reported to the Care Quality Commission and this meant we could not monitor the service appropriately to make sure people were safe.” from the report
Laundry arrangements
needs fixingThe laundry facilities remained in the kitchen, despite a recommendation at the previous inspection to consider moving them. Red bags had been introduced to separate soiled laundry.
“The washing machine remained in the kitchen.” from the report
- 01What action has been completed to address the fire risk assessment, and when was the work independently checked?
- 02Have all bedroom window restrictors, broken tiles, the boiler cupboard and the fridge been repaired or replaced, and how are these checks recorded?
- 03How are food storage, cleaning chemicals, hand-drying facilities and the kitchen laundry arrangements managed now?
- 04What changes have been made so staff understand the management structure and all reportable events are notified to CQC?
- 05What improvements have been made since the warning notice, and what evidence can you show that the action plan is complete?
This was a focused inspection of Safe and Well-led only; the other key question ratings were not inspected and previous ratings were used to calculate the overall rating. This explanation was written from the published report of 5 January 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Serenity UK Limited
3 rated inspections over 5 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2023Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- June 2018GoodSafe: GoodWell-led: Good
- May 2016
Registered with the Care Quality Commission on 16 May 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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