Amber Court Residential Care 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.

At our last assessment we rated this key question good. At this assessment the rating has changed to 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 continued breach of legal regulation in relation to capacity and consent.

This service scored 46 (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 always make sure people’s care and treatment were effective.

We saw there were assessments completed with people and families where appropriate, before they started using the service. The system in place did not always ensure these assessments were used to create a care plan that met people’s assessed needs, we could not be assured these assessments were always effectively used to deliver consistent care.

People and relatives raised no concerns with their involvement with the assessment process.

The provider did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

The manager told us they had a system in place which used evidence-based tools to assess people’s needs. The records we viewed did not support this, for example, 1 person had a falls assessment in place that not been reviewed since 2024, despite this person experiencing a number of falls. We found people’s pressure needs were not always documented and when people displayed periods of emotional distress it was unclear how incidents had been used to develop care plans and risk assessments for people as incidents or behaviours were not referenced in guidance for staff.

Other people had assessment tools in place that were used to assess their needs, however as described these were inconsistently completed.

Staff were able to describe how they delivered care to people and told us they understood people’s needs. However, as care was not always delivered safely, we could not be assured this feedback was always accurate.

The provider did not always work well across teams and services to support people.

There was a system in place to ensure people received support from other professionals if needed. We could not be assured this advice was always followed as care plans had not always been updated to reflect this advice and when areas of improvement had been identified, action had not always been taken to address these concerns. For example, 1 person had been seen by a Speech and Language Therapist (SALT) but the new recommendations were not recorded in any of the plans or guidance in place for this person and placed this person of not receiving support in line with this. The information we reviewed confirmed the person was receiving adequate fluids.

Staff shared information electronically about people through daily notes. They attended handovers and regular ‘flash’ meeting to discuss people’s needs. Since our last inspection the provider told us they had introduced 3 further meetings throughout the day, where people’s needs were discussed. These were the 10@10, 6@6 and 2@2 meetings.

People raised no concerns with how staff worked together to share information.

The provider did not always support people to manage their health and wellbeing to maximise their independence, choice and control.

Staff were aware of people’s health needs and the support they needed. People’s health needs were assessed; however, plans did not always contain accurate up to date information about people which placed them at risk of not receiving the support they needed. In some areas we saw improvements had been made and when people had diabetes for example, we saw care plans were in place and these were followed.

People and relatives confirmed people’s health needs were responded to.One person told us how they became unwell, had seen the GP and were now prescribed antibiotics.

Staff were aware of people’s health needs and the support they needed. People’s health needs were assessed, and plans were in place to monitor these conditions.

The provider did not always routinely monitor people’s care and treatment to continuously improve it.

We received mixed feedback on the outcomes people received. One person told us, “Last week the manager, who I like and is very nice, organised for me to have a shower. I haven’t had one since I came in, they just washed me. They didn’t offer me a shower. So I had a shower last week, but they haven’t offered me one since. It felt lovely.” Another person said, “They do weigh me, and my weight is stable.”

As care plans and risk assessments were not always followed, reflective of people’s needs, reviewed or up to date, the systems in place to review and monitor care for people was not always effective.

The provider did not always work within the principles of The Mental Capacity Act 2005.

At our last inspection we found there were capacity assessments in place for people when needed, however, these had not always considered all aspects of people’s care. There was not always evidence to show how decisions had been made in people’s best interests. When people lacked capacity to make decisions, relatives had consented on their behalf without the legal powers to do so. At this inspection we found the same concerns.

After our last inspection we asked the provider for an action plan to show us how they were going to comply with this regulation, they told us they would take the following action including, implementing stronger best interest procedures, ensuring the best interest meetings were held for the service users who lacked capacity and they would review care plans regularly to check if restrictions could be reduced over time. We found the provider had not taken the action they told us they would; this placed people at risk of being unlawfully restricted.

People raised no concerns with how they consented to their care. Staff told us they had received in MCA and DoLS since our last inspection.