Amber Lodge Nursing Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

This is the first assessment of this location under a new provider. This key question has been rated requires improvement. This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 50 (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 make sure people’s care and treatment was effective because care plans and risk assessments were not always up to date and did not always contain all relevant information.

There was no care plan in place for the care of a person with epilepsy. When equipment was used to help people transfer, care plans and risk assessments lacked details on the specific equipment used. Care plan information had not always been updated. For example, care plans lacked detail on a person’s plans for emergency care and treatment, some people’s Deprivation of Liberty Safeguards, and that a person would often refuse offers of personal care and what was in place to manage this.

The provider did not effectively plan and deliver people’s care and treatment. They did not follow legislation and current evidence-based good practice and standards. For example, staff had not made sure a person with dysphagia was positioned to help mitigate the risks of aspirating their food and fluids when assisting them with their meal. Nor had they paced their assistance to allow the person to pause between spoonfuls, despite the person coughing.

One relative told us, “[Family member] does not always get their drinks and they have a lot of urine infections.” We observed one person’s water jug level had not changed over the course of the morning and we asked staff to see if they would like a drink. They drank thirstily when staff assisted them with a glass of juice. Whilst staff had recorded this person had been assisted with hot drinks during the morning they were ready for a cold drink when we prompted staff to check. Whilst staff maintained records of what people had eaten and drank, the provider confirmed these were not always accurate. Therefore, we were not assured people were prompted to drink enough fluids.

Staff showed people the plated-up meal options available to help people make their food choices. People’s weight was monitored to ensure they maintained a healthy weight.

The provider worked well across teams and services to support people.

Staff told us recent changes had improved how their workload was allocated. Information was shared with other health and social care professionals on people’s needs when needed, for example, when referrals for other services and support were made. We saw messages were able to be sent to staff to update them quickly on any changes or updates. Team meetings were arranged and the manager held daily meetings to maintain oversight of the different functions of the service.

The provider supported people to manage their health and wellbeing to maximise their independence, choice and control. Staff supported people to live healthier lives and where possible, reduce their future needs for care and support. One person told us, “When I first came in, I was hoisted, now I can walk a few steps, I have got a lot better.”

Staff made referrals when needed to other healthcare services to help people with their independence and health. One staff member told us, “We’ve had the physiotherapist involved and this has helped to reduce their falls.”

The provider did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

One person had not been monitored for epileptic seizures as there was no care plan in place to guide staff on what to look for, what they needed to do and how to record and monitor any suspected seizures. We found several descriptions in the person’s daily notes that may have been related to seizure activity however, these had not been identified and reviewed clinically to see if they were.

Another person required their urine output monitoring as they had a catheter. This was not in place. People’s food and fluid intakes were not accurately recorded. Therefore, the provider would not be able to quickly identify changes and take any action to maintain their safety and well-being.

When people needed their glucose levels monitoring this was completed.

The provider told people about their rights around consent and respected these when delivering person-centred care and treatment.

We observed staff asked people for their consent for care before it was provided. This helped respect people’s rights.