Arden Park

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe

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.

Good: This meant people were safe and protected from avoidable harm.

This service scored 66 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Relatives told us they knew how to raise concerns and felt listened to and acted upon by the service. One relative told us, ‘I would speak to the manager, or I would speak to the staff and they listen and act on it’. People and relatives were informed following incidents such as falls, staff understood how and where to record such events. The service promptly investigated accidents and incidents however we found a lack of detail stating what action was taken and who took it. We did not find an audit trail on if lessons had been learnt.

The service demonstrated a willingness to work with health and social care professionals and acted on any advice given. One healthcare professional told us, “If I ask to do something different, advice is followed. Example [person] needed to put legs up, since the service were asked to do so I noticed the [person] is always supported to have their legs elevated”.

Systems were in place to ensure the registered manager had investigated accidents and incidents however further processes needed to be developed to ensure lessons learnt was shared with staff through staff meetings and 1:1 with their manager.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Relatives told us the service worked with them before people moved in to ensure a smooth transition. One relative told us, “They asked me lots of information about [person] before they moved in”. Another relative told us how they were able to settle their loved one in whilst staff sat and chatted to them. The registered manager had a process in place to establish a care plan with people, relatives and partners prior to people moving in. Which helped to ensure risks were managed and people received continuity of care.

Staff told us when a new person moved in management updated them with the person’s needs. In addition, information was recorded on the services electronic records system and in the communication book. A care staff member told us in the event of an emergency admission to hospital they would look after the person whilst paramedics were awaited. Leaving senior staff free to “Do the paperwork and get the medicines ready.”

The service worked closely with health and social care professionals to ensure continuity of care. One healthcare professional told us, ‘We work with them and have a very good relationship. I know the people well’.

Processes were in place to ensure risks to people were managed and made available to other health and social care professionals where appropriate. The service responded to individual’s needs ensuring people had access to services in a timely and effective way.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

The service had safeguarding systems in place which helped to protect people from avoidable harm. A person told us “Oh yes, I feel safe here”. Relatives were confident to raise concerns with management and staff. One relative told us, “I feel that [person] is safe, the home is very secure”. Another relative said “[Person] is happy and content. When I visit, they are happy and their needs are being met”.

Staff had the relevant training in relation to safeguarding and the Mental Capacity Act (MCA). They understood their responsibilities to protect people from abuse. Staff understood the concept of Deprivation of Liberty Safeguards (DoLS) however they were less clear what it meant. The provider agreed to provide further training to care staff. Staff knew how to recognise and respond to safeguarding concerns and how to escalate them internally and externally. Staff were confident if they raised any concerns for people’s safety the registered manager and senior staff would take steps to assist them. Systems were in place to ensure applications to deprive a person of their liberty were made in a timely way, and any conditions observed.

Health and social care professionals reported the registered manager worked proactively with them when a concern was raised. One health and social care professional told us, “When a safeguarding alert comes, they have already contacted and involved people, the notification came almost after they had started the process and got people in”.

Systems and processes were in place to log accidents, incidents and safeguarding concerns with regular oversight from the provider.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

One person told us they were at risk of falls, but said staff worked at their pace when caring for them, which reduced the likelihood of them experiencing falls. Care plans had detailed information on how best to support people using appropriate equipment to reduce risks. In addition, a separate risk assessment was in place which covered smoking and the use of equipment which was subject to regular reviews. However, staff we spoke with told us of a person’s individual risk assessment and home risk assessment for smoking which did not reflect what happened in practice; there was an expectation the person would smoke outside, but staff were aware of the person smoking within the building. Risk of smoking inside were not reflected in their care plan or risk assessments. In addition, some areas of the separate risk assessment required additional detail, to ensure staff had effective guidance to follow.

Staff worked at people’s own pace when supporting them to move around the home. One staff member told us, “Safety is managed well here, [people] are taken care of and safe.” Another staff member told us they felt supported to provide good care to people and to reduce people’s risks because the correct equipment was available to help them to do this. Staff were provided with a good level of guidance in managing people’s health risks and clear instructions on when to escalate to seniors.

Systems were in place to record and manage risks however these needed to be more detailed and robust to highlight what is happening and to ensure it is consistently followed by people and staff.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

There were regular visual checks of the environment. However, we were not assured that all environmental risks had been identified and acted upon. During the inspection, we identified several environmental and safety issues across the service. In the room being used by inspectors which was also used as a lounge, a cupboard door hinge required repair. There were areas of the home on the ground floor where there was a noticeable smell of urine, and the toilet located next to the electrical cupboard on the ground floor showed evidence of a leak to the ceiling, with unknown liquid substance present on the floor.

We found that a cupboard near the kitchen containing cleaning consumables was left unlocked. In the laundry area, the bin was not foot-operated, we found powder used to thicken peoples drinks also in an unlocked cupboard. When we fed this back, staff reported difficulty locating the key for the cupboard. Thickeners should be stored securely to reduce risks of accidental consumption.

Further concerns were identified relating to fire safety. For example, wheelchairs were stored inappropriately in a way that could restrict safe egress from the building in the event of a fire. There was a smell of smoke in a corridor near a bedroom: the deputy manager told us that a person had recently requested a cigarette and believed they may have smoked in a nearby toilet. Additionally, a cupboard labelled “Fire risk-keep locked” on the first floor was found unlocked and open on the first day of the inspection.

The services fire risk assessment had already identified that some doors required additional hinges, and we observed that some doors did not close properly, which could place people at risk of harm. Outside potholes in the car park were also noted as requiring attention.

We raised these concerns with senior staff during the inspection, who took immediate action to begin addressing some of the issues identified.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People told us there was enough staff to provide the support they wanted. One person said, “You don’t have to wait long if you want help from staff.” We asked relatives their view on staffing levels, one relative said, “Yes when I am there, there always seem to be lots of staff around”.

Staff told us they felt supported by management. One staff member told us, “They [provider] reduces staffing levels if occupancy falls. It can be hard, but the deputy and senior staff will come and help on the floor. They are good.” Another staff member said, “There is enough [staff] in the day, it’s a bit light at nights, but not a safety issue, it is just general availability of staff.” The cleaner said her days off were covered by bank staff.

Safe recruitment processes were in place to ensure all required checks were completed before staff started work at the service. Enhanced Disclosure and Barring Service (DBS) checks were carried out. DBS checks provide information about convictions and cautions held on the police national computer. The information helps employers make safer recruitment decisions.

The provider offered comprehensive training to staff to ensure they developed and maintained the skills and knowledge to support people effectively and safely. A staff member told us, “We have face to face training for manual handling and fire training.” Another staff member told us some people required support from 2 staff when moving around the home. The staff member said a second staff member was always available to assist when required. Systems were in place to manage staff training, completion rates for majority of the staff were 99%. Staff training records showed staff had completed training in health and safety and fire safety.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified some areas which needed improvement. Some skirting boards in toilets were not cleaned, bins did not have foot operated lids, there was a leak in the ceiling, and a strong odour in the corridor. Which could increase the risk of the spread of infections. In the kitchen we found food was not always managed in accordance with good practice. Food labels were not appropriately labelled with opened and use by dates. The registered manager and provider had a range of Infection Prevention and Control (IPC) audits in place. However, these checks had not promptly driven through improvement. Previous audits had highlighted areas of improvement with a deadline for completion; however, these had not been followed through. We spoke with the management team who started to address the issues during the assessment.

People and relatives were happy with the cleanliness of the home. One relative told us, “They are always cleaning when I visit”. Another relative said, “[Person’s] room is always clean and warm”. Overall, we found the home clean and well maintained. Policies and procedures were in place and staff understood their responsibilities to promote safe infection control practices

Staff told us there had not been any recent infectious outbreaks at the home and described working in an environment where they were supported to provide safe care and reduce the likelihood of the spread of infections through sufficient consumables and information sharing. Staff were provided and used personal protective equipment (PPE) appropriate for the care they delivered and the level of infection risk.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

One person said they sometimes experienced pain but could count on staff supporting them to have the medicines they needed to reduce the pain they had. Another person told us they had needed PRN medicines (as and when), which was sorted quickly by staff. Another person said staff obtained additional medicines from their GP when they had recently been ill.

Medicines were managed safely and effectively. Medicines were stored, administered and disposed of appropriately. Staff received training and their competency was assessed on a regular basis. However, there were some inconsistencies in guidance for application of creams. Guidance for staff on how to apply transdermal patches (pain relief) wasn’t clear and body maps were available to support with this but not always effectively used. Staff could tell us the process for rotation however records did not reflect this. There was an absence of recording of opening and dispose by dates on people’s medicinal creams which had been highlighted in the provider audits in July and August 2025 however we couldn’t see any actions to improve this practice.

The service demonstrated a proactive approach in identifying medication reviews. Covert medication was evidenced to be in place for the one person in receipt of the medication, however it was not clear if it was administered on a daily fixed or PRN (as and when) basis. We raised this with the deputy manager who advised it had started as PRN however the GP had amended the protocol to fixed however this had not been updated on person’s records.

Systems were in place to ensure stocks, balances and records showed people consistently received their medicines as prescribed.