Arden House

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Governance processes were not always effective to ensure continuous improvement.

The service was in breach of legal regulation in relation to governance at the service.

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.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were positive about working at Arden House and demonstrated empathy and compassion for the people they supported. The provider’s values included respect, openness and honesty and we saw these were embedded by staff throughout the home.

The provider had taken the registered manager out of the service 6 months prior to our inspection to support another service in the provider group. This had impacted on the registered manager’s level of oversight at Arden House. People and staff told us the registered manager was approachable, and they could speak to them when needed. In the absence of the registered manager, they had been supported by the deputy manager and team leaders within the home.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff were positive about the leadership within the home and the support from the provider. Comments included: "We have got good support from management and from head office. Any queries, the manager is on the ball with policy, and health and safety at head office are always contactable if you have a query" and "Even if they (registered and deputy manager) are not in, their numbers are in the staff room so we can always call them. Even on holiday, they still take 'phone calls."

The provider had commissioned an interim manager at Arden House during the 6 months the registered manager had been working at another home within the provider organisation. Feedback varied about the level of oversight and support staff had received during this period. The registered manager shared that they had raised their own concerns to the provider and would be remaining at Arden House full time following our inspection.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff felt confident to share any concerns they had and to make suggestions about service provision at Arden House. Staff told us they felt listened to and that their views were respected. One staff member said, “The manager is good because if I have a problem, I know I can go and talk to her." A second staff member told us, “Staff will sometimes bring things up and they (managers) will say ‘yes but’ and give us the reason why it is not a good idea. If it is (a good idea), they will say that is a brilliant idea." A third member of staff commented, “I feel they really do trust my judgement with the new ideas I bring. I don’t think there has ever been a time when they have said they don’t think it will work, but rather we will give it a go and see if the residents like it."

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff told us they felt valued. They said diversity within the workforce was respected and they would challenge any discrimination if it was witnessed. One staff member told us, “If I saw someone treated badly, I wouldn’t be here." Another staff member said, “They are very inclusive and always give everyone a fair opportunity here." One staff member told us a memo had been shared with staff reinforcing consideration for those staff with menopause symptoms.

Events had been held throughout the year to recognise and reward staff’s individual qualities. Staff told us the registered manager had encouraged team building through organised events and thoughtful gestures such as a ‘pizza night’ and ‘garden parties.’

Staff described a culture where learning was encouraged and supported. One newer member of staff told us they felt able to approach other staff for advice and commented, “Nobody ever talks down to me; it is about educating me and me learning how to do things." The service had achieved Investors in People Gold accreditation in recognition of their commitment to creating a workplace where staff could thrive and develop.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. The provider had governance systems to monitor and improve quality; however, these were not always effective.

Governance systems were not always effective because issues we identified during this inspection had not been identified by the provider’s own governance processes. This included issues around consent, mental capacity assessments, best interests’ documentation, the accurate completion of risk assessment tools and monitoring of the effectiveness of risk management strategies. The provider was also moving towards an electronic care planning system and preparatory work for the transition had led to inconsistency in care plans and documentation. Some audit tools used by staff were completed using a scoring system from 1-4 but lacked information to detail why specific scores or answers had been selected. Identified actions from audits were not always monitored and followed up effectively. The registered manager acknowledged that governance processes had not been effective during the period they had been away from the home.

When the provider had commissioned audits of the home, we found these were not always effective and not always reflective of the service. For example, an audit completed by the provider’s quality auditor had ticked yes to the question, ‘CQC rating poster is printed and displayed clearly’; despite the fact it was not in place at the time of our visit. The registered manager confirmed it had not been displayed since the last inspection as they were unaware it needed to be. There is a legal obligation for providers to do so. The registered manger took immediate action to display the ratings poster as required.

The service had not sustained their compliance since the last inspection, resulting in breaches of the regulations being identified.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

People were encouraged to remain part of the local community and the registered manager invited a range of local groups into the home including schools, knitting clubs and local charities.

Some people had been involved in growing plants and contributing to ‘Leamington in Bloom,’ and others had been invited to a local tea dance by a community group.

Relatives told us they were kept updated and informed of any changes to their family members care, either in person or by telephone. We saw examples of staff working in partnership with relatives to achieve positive outcomes.

The provider was focused on continuous learning, innovation and improvement across the organisation and local system. However not all improvement actions had been evidenced as completed or embedded.

The home did not have robust quality assurance systems in place to ensure continuous improvement. For example, the provider was aware that at the last inspection we had concerns around staff’s understanding of MCA’s and DoLS. This remained a concern at this inspection.