Amaana Care Also known as 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.

This is the first assessment for this newly registered service. This key question has been rated requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

This service scored 39 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had experienced a number of managerial changes within a short period, which contributed to inconsistency and a lack of clear direction. As a result, the service did not demonstrate a shared vision, strategy, or culture grounded in transparency, equity, and equality.
Although staff and leaders we spoke with described promoting people’s independence and enabling positive outcomes, we did not consistently observe this in practice. For example, safeguarding concerns were not always identified or reported, we found issues in the reporting of incidents and accidents. This increased the risk the service did not consistently maintain a positive listening culture. A relative said, “I don’t get the impression that the owner cares about the residents. The general care and food is very basic.”
 

The service did not demonstrate they had capable leadership with the right skills and knowledge. We identified breaches of the legal regulations and concerns in areas such as safeguarding, safe care, staffing, consent and governance. Leaders had not independently identified and acted on these concerns prior to our assessment. Although staff felt they could approach leaders with concerns and they would be addressed, leaders were not always proactive in identifying poor practices that could impact the quality of people’s care and well-being. One relative said, “I am hoping for some stability which would enthuse the day-to-day staff. They are struggling. There is room for improvement.”

Although governance systems demonstrated that incidents, complaints and safeguarding concerns were reviewed, we were not always assured that incidents and safeguarding concerns were consistently identified or escalated in a timely way. This meant we could not be fully assured that people and their relatives were always informed promptly or received an apology when things went wrong. However, a relative said, “I am confident that any concerns would be taken seriously.” Another relative told us, “The only concern I have is getting through to the manager. There have been four or five different managers in the year [Person] has been in the Home, so the management is unstable.”

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 did not raise any concerns with us about their treatment.

The service did not have good governance systems in place. They did not act on the best information available to them about risk, performance and outcomes. The provider had not identified concerns related to safeguarding, managing risks, medicines, the safety of the environment, care planning, staff knowledge and skills and the need for consent. We found people were at risk of being exposed to harm during this inspection.

Partnership working was evident in some areas, including engagement with healthcare professionals and external agencies. However, this was not always effective in ensuring seamless care, timely identification of concerns, or appropriate information sharing. The provider had not always identified issues found during this assessment and therefore did not consistently share incidents, concerns or learning with relevant partners. For example, we identified a number of incidents that had not been recognised by the provider and had not been reported to the local authority safeguarding team or CQC.

The provider did not demonstrate a culture of learning, improvement, or innovation. Systems to identify, review, and act on risks and concerns were ineffective, meaning opportunities to improve care were missed. For example, there was limited evidence of structured audits, quality assurance processes, or review systems being used to monitor performance and drive improvement. Where concerns had been identified, actions were reactive rather than part of a planned and monitored improvement process. Although some immediate actions were taken during the inspection, such as seeking guidance on medicines processes and arranging training, these were in response to identified concerns rather than demonstrating an established culture of continuous improvement.