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Inspection Summary

Overall summary & rating


Updated 15 October 2019

About the service

Amberley House – London is a residential care home providing accommodation and personal care for up to 30 people aged 65 and over, some of whom may have dementia. At the time of the inspection there were 29 people living at the home. The home is a large adapted detached residential house. There is a well-appointed, large garden to the rear of the property.

People’s experience of using this service and what we found

People told us that they felt safe living at Amberley House. Feedback from relatives was also positive. However, we found significant concerns around how the home was managed, documentation relating to care, cleanliness and ensuring people’s psychological needs were met.

People’s personal risks were not always assessed. Where risks were assessed, risk assessment documents failed to provide adequate guidance to staff. People received their medicines safely and on time. However, we found that systems to safely monitor medicines were ineffective. Staff recruitment was not always safe or consistent.

People’s bedrooms were not always clean, furniture was often unsafe and in a poor state of repair. Whilst the provider took remedial action when this was pointed out, there were not adequate systems in place to identify this prior to the inspection. Infection control was not always well managed.

Staff did not have enough time to spend with people. There was no system in place to ensure that there was sufficient staffing to make sure people were adequately supported in all aspects of their care.

We observed caring and warm interactions between staff and people. However, we also observed interactions that were not as caring where people’s privacy and dignity was not respected.

Care plans were not person centred and failed to give staff guidance on how to work with people as individuals. People were observed to be sitting in the communal lounge with very few activities or stimulation. There were no formalised activity timetable and people were not supported to follow their interests. People did not always have a choice of what they wanted to eat and were not involved in menu planning.

People were not supported to have maximum choice and control of their lives. People did not always have choice around every day decisions such as, what they wanted to eat or if they wanted to go out.

There was a lack of managerial oversight of the home. There were no effective audits of any aspect of care delivery. Documentation, including care plans and risk assessments, were not always up-to-date. There was no deputy manager in post and the registered manager had no support to maintain an effective level of oversight of the home.

Staff understood safeguarding and how to keep people safe from abuse. Staff received regular training to support them in their role.

For more details, please see the full report which is on the CQC website at

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Rating at last inspection: At the last inspection the service w

Inspection areas



Updated 15 October 2019

The service was not safe.

Details are in our safe findings below.


Requires improvement

Updated 15 October 2019

The service was not always effective.

Details are in our effective findings below.


Requires improvement

Updated 15 October 2019

The service was not always caring.

Details are in our caring findings below.


Requires improvement

Updated 15 October 2019

The service was not always responsive.

Details are in our responsive findings below.



Updated 15 October 2019

The service was not well-led.

Details are in our well-Led findings below.