Amaana Care Also known as Arden House

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

This is the first assessment for this newly registered service. This key question has been rated inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to safe care and treatment, safeguarding and staffing.

This service scored 31 (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 did not have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety or consistently investigate and report safety events, and lessons were not learned to improve practice. For example, we identified incidents involving periods of emotional distress between people using the service were recorded; however, these were not escalated to external safeguarding authorities or used to drive learning and improve safety systems.

The service did not always maintain safe systems of care to manage risks people could experience or be exposed to. Safeguarding concerns were not always identified, health risks to people were not always well managed, and care plans did not always reflect people’s needs. However, the service worked with healthcare partners when they had identified concerns such as people experiencing ill or deteriorating health.

The provider did not protect people from abuse or ensure concerns were shared appropriately with relevant agencies. For example, incidents included a person exposing themselves to others, physical assaults between people, and an incident where one person entered another person’s room and caused injury. Despite the seriousness of these events, no safeguarding referrals had been made to the local authority until we raised our concerns with the provider. There was no evidence of escalation beyond internal recording or of measures put in place to protect people from further harm. This meant people were at ongoing risk of abuse, improper treatment, and neglect.

The provider did not always work with people to understand and manage risks in a person-centred way.
For example, there was limited evidence of individualised risk assessments being completed to identify or mitigate risks such as emotional distress, mobility needs, or environmental hazards. Whilst we found some examples of person centred risk management, care plans did not always clearly outline how risks should be managed. This meant staff did not always have clear guidance to deliver safe care, and people were not always supported.

The provider did not detect, assess, or control risks within the environment.
For example, we identified multiple hazards including excessive hot water temperatures and exposed radiators presenting scald risks; fire safety failures such as wedged fire doors, doors not self-closing, and lack of fire safety testing records. This created an unsafe environment and exposed people to avoidable risk of harm. A relative told us, “The building could do with a lick of paint. Bits and pieces are hanging off the wall but it is generally ok.” Another relative said, “The outside of the home needs sprucing up, and a lick of paint, and the windows need renewing, but [Person’s] room is always clean.”

 

The provider did not ensure there were sufficiently skilled, competent, and supported staff to deliver safe care. For example, agency staff were working in the service without evidence of induction, competency assessment, or assurance checks. Staff reported working multiple shifts without formal onboarding or training. Inspectors directly observed unsafe moving and handling practices, and the registered manager was unable to confirm staff competency. This meant people were at risk of harm due to unsafe care practices and lack of staff training. A relative said, “The home is like a rudderless ship. No one knows what they should do as they have no guidance as to what their next job should be. It is frustrating.” Another said, “The staff have seen quite a few changes. There are one or two stable members of staff, but I see a number of carers have changed and the carers fluctuate.”

The provider did not assess or manage the risks of infection prevention and control.
For example, we observed visibly dirty areas including toilet pull cords, floors, and fixtures; inappropriate waste management such as clinical waste stored in incorrect bags; and unsafe laundry practices where cleaning cloths were washed at insufficient temperatures. In addition, equipment such as fly zappers was not maintained, and personal protective equipment was disposed of incorrectly. This increased the risk of infection spreading within the service.
 

The provider did not ensure medicines were managed safely or in line with legal requirements.
For example, covert medicines were administered without appropriate best interest decisions, care plans, or authorisation under deprivation of liberty safeguards (DoLS). People were given medicines covertly without evidence of consent or appropriate legal framework. In addition, the medicines room temperature exceeded safe limits with records showing this had been the situation for over 4 weeks, and liquid medicines were not appropriately labelled with opening dates. During inspection, staff did not consistently observe people taking medicines to confirm ingestion. This placed people at risk of unsafe treatment and raised concerns about the protection of people’s human rights.