Arden Park

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

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 remained good.

Good: This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 68 (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.

Leaders worked with people, their representatives and staff to build a culture that focused on enabling people to enjoy their lives. One person said, “I like the way the place is run because you can talk to anyone. [Registered manager’s name] is great, if you need to speak to her, you can. You just knock the office door, and they pop out and see how the staff are doing.” We spoke with 2 other people. One said, “This place is brilliant, staff are the best and treat you like a person.” The other person said, “This makes a difference.”

A staff member told us the focus was to look after the residents and that they enjoyed doing it. However, another staff member told us they were not sure what senior staff wanted for people living at the home and said they were not always sure if staff suggestions were followed through. Another staff member said the best thing about working at the home was, “We have a good team”, but explained there were sometimes tensions within the staff team.”

The service promoted equality and diversity in the workplace to tackle inequalities. The registered manager shared example of how they researched a particular disability following a staff member’s disclosure. Demonstrating how they helped to ensure they were able to provide support and remove any barriers the staff member may have experienced.

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. However not all leaders had the skills, knowledge and experience.

We found the management team to be welcoming, proactive, and demonstrated transparency and openness. However, we identified areas of improvement that had not been followed through as highlighted in the audits. Systems and processes needed to be reviewed to ensure provider and registered manager were aware of outstanding actions and ensured they were completed and checked as part of quality assurance.

One relative told us, “They [management] are visible and I can talk to them, they are approachable”. Another relative said, “I know the manager and I can speak to them if I need them”.

We observed warm and friendly interactions between people, staff and relatives. The registered manager spent time talking to people, acknowledging what they did well and praising them. A staff member said there had been changes in the management team, however the change had not impacted on people or staff.

Health and social care professionals told us, “I know they are very obliging, anything I ask for I have the answer or given information to look at. It's one I never get concerned about or phone in advance. I think it's Arden I will get everything I need”.

Staff reported managers were always available to offer support and provide additional training or explain in a way they understood. Throughout the assessment the management team responded proactively to our findings and took prompt action to address shortfalls identified.

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

The provider had processes in place to support staff to speak up, including team meetings, supervisions, handovers and digital reception. Staff told us they felt supported and able to raise concerns with the management team. A staff member we spoke with was aware how to raise any concerns internally and externally. They understood how it was different for people and staff.

The registered manager told us they had an open-door policy and understood the importance of confidentiality. Systems were in place to ensure the provider had an oversight of any concerns this had been audited as part of quality control.

Feedback was actively gathered from people, relatives using the service as well as staff to drive improvements where needed. People, relatives and professionals spoke positively about the management team.

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.

The service had a diverse workforce and worked towards a supportive culture that promoted inclusion and equity. Staff told us they were happy and gave examples of how they were supported and felt valued. The registered manager gave an example of how they familiarised themselves with conditions staff may have. Which enabled them to provide appropriate support to staff and make any necessary adjustments which would help them in their caring role.

Staff demonstrated a good working relationship amongst each other with one staff member referring to a colleague as their “work sister”. It evidenced how staff teams worked collaboratively together to support people living at the home.

Policies and procedures were in place which incorporated all aspects of safe recruitment such as equality, diversity and fairness.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider had an oversight of the service but needed to further develop their governance systems to ensure actions identified were promptly progressed and improvements embedded. For example, regular audits, visits to the home and checks were completed by a compliance manager. These checks included risk and quality of people’s care and support, feedback from people, relatives and staff. Any shortfalls were fed back to the registered manager; however, these identified risks were not always actioned. We found previous audits had identified creams that had not been dated and wheelchairs under the stairs. One staff member said they were able to get good advice from the deputy, but the manager was a bit newer, so had not tested it out with the registered manager yet. Staff told us they regularly saw provider representatives.

Audits and checks were in place to oversee good service delivery and ensure people’s safety. The registered manager and provider had a comprehensive check and undertook a broad range of audits, covering areas such as medicines and health and safety. One staff member said, “[operations manager] checks on people’s rooms, their care and if we are brushing their teeth”. However, some identified areas of improvement were not promptly addressed or followed up. For example, whilst fire safety and management checks were undertaken these had not ensured fire risk assessment action plans were fully completed, and daily checks had not ensured all areas which required to be secure were locked as required. Which included areas where people may be at risk. The provider started to address our concerns during the assessment.

The provider had a process in place to monitor feedback and take appropriate action when required. Processes were in place to ensure complaints were logged and investigations took place in line with policies and procedures. However, the registered manager also needed to have oversight and involvement in the process. We raised it with the provider who assured us it would be reviewed.

The provider was aware of their statutory duty to notify CQC of any changes, events and incidents that affected their service or the people using it. These notifications were submitted in a timely manner.

Systems and audits were in place to monitor care delivery out of hours, for example the registered manager told us regular unannounced visits were undertaken at night. A nurse call system was in place however it had not been regularly reviewed, the registered manager assured us it would be included in future audits. The fire risk assessment action plan needed to be clearer to demonstrate which actions had been completed and when. The provider oversight had not promptly driven through improvements.

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.

The registered manager and staff had developed positive working relationships with services who supported people living at the home. Evidenced through interviews we held with health and social care professionals. People and relatives told us they felt involved in decision making. People and relatives’ meeting minutes demonstrated people had been given opportunities to share their views on what was important to them such as activities, menu and food.

Staff knew how to contact external professionals and make relevant referrals to help meet people’s changing and ongoing needs.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

There were systems in place to ensure staff were given regular opportunities for professional development through the provider’s structured training programme. These were delivered through a combination of online platforms and face-to-face sessions.

The registered manager attended the provider’s regular registered manager’s meetings and used it as an opportunity to network and share best practice with colleagues. The provider and registered manager had worked collaboratively with the local authority’s quality monitoring team to improve the service.

The provider and registered manager genuinely welcomed feedback, even if it was critical and demonstrated what actions had been taken in response. They engaged positively with our inspection, responded to queries and acted promptly on concerns raised. For example, to environmental issues and documentation.

Processes were in place to continually drive improvement within the service; however, these needed to be developed further to enhance service delivery.