Arden House

At our last assessment, we found the service was in breach of legal regulations relating to consent and good governance. We asked the provider to send us an action plan telling us what actions they would make to improve. We carried out this assessment to ensure the actions had been taken.

At this assessment we found sufficient improvements had been made, in relation to the breach of regulations in consent, however concerns around oversight and compliance meant the provider remained in breach of regulations in good governance.

Since our last assessment, the registered manager had changed roles within the provider organisation and there was no registered manager in post. An interim manager was providing support, whilst continuing to fulfil their regulatory responsibilities at their own service. There had also been changes at senior leadership level, with a new nominated individual (NI) in post, and changes within the provider’s governance and compliance team.

The provider had not ensured all improvement actions were taken as we were told they would be. Despite the provider being aware of concerns identified at the previous assessment, sufficient improvements had not been made and there remained weaknesses in governance and oversight processes. Management capacity was reduced following the departure of the registered manager, and the provider had not taken effective action to address known staffing and leadership capacity issues. As a result, quality assurance processes failed to identify and address a range of concerns relating to care records, monitoring systems, and regulatory compliance.

Care records were not always accurate, complete or up to date. The transition to an electronic care planning system had not been effectively managed, resulting in some records remaining paper based and not being regularly reviewed. This meant staff did not always have access to clear and consistent information about people's needs. Monitoring systems were not always used effectively, and opportunities to identify deterioration and improve outcomes were sometimes missed.

Although staff worked hard to meet people's needs and there were examples of good practice, improvements were required to ensure governance systems were effective, risks were consistently identified and managed, and people received safe, high-quality care that was consistently monitored and reviewed.