Amber Court Residential Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in continued breach of 2 legal regulations in relation to people’s safe care and treatment and how people were protected from potential abuse.

This service scored 34 (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 have a proactive and positive culture of safety based on openness and honesty. They did not always investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The systems and processes in place continued to not effectively ensure people were supported in a safe way. When incidents had occurred and were recorded, for example, unwitnessed falls, there was not always an investigation or review to consider and mitigate the risk of reoccurrence. There was no detailed overall analysis of incidents which occurred, so that trends could be considered and therefore action had not been taken to identify any areas of learning.

Both the Local Authority and the Integrated Care Board (ICB) had recently completed site visits at the home and had given the provider feedback and areas of improvement. Despite this, we found timely action had not always been taken to address concerns. For example, they had identified in May 2025 face masks being used by staff had expired, and multiple examples of where people’s pressure relief had not been recorded in line with their care plans. We found this had not been acted upon during our inspection.

The provider told us they had made various improvements since the last inspection to ensure lessons had been learnt, this included the introduction of the PCS electronic care management system. They told us this had ensured residents’ needs were addressed promptly and effectively; however, we saw information that had been inputted into the system was sometimes inaccurate, out and date and often not in place at all. This meant this system had not been effective in bringing about the changes the provider told us it did.

The provider did not always ensure, establish and maintain safe systems of care.

Despite the improvements the provider told us had been made, the he provider had not made the necessary improvements since the last inspection and there were not always care plans, risk assessments or up to date guidance in place for staff to follow, including when there were known risks to people.

Care plans and risk assessments were not always updated when changes or incidents occurred. It was not clear how people and those that were important to them were involved with the process. This placed people at risk of receiving unsafe and/or unsuitable care.

There was a pre assessment process in place which ensured people’s needs could be met before they moved into the home. People we spoke with felt they were involved with this process and raised no concerns to us.

The provider did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

At our last inspection we found safeguarding concerns were not always appropriately investigated or reported and we asked the provider to take action. At this inspection we again found the same concerns and there had been no improvement, despite the improvements the provider told us they had made.

There were procedures to identify and report safeguarding concerns however these were not always followed. One person had been involved in an incident which the provider described had resulted in a ‘major injury’. The records showed this person was not supported by the correct number of assessed staff at this time. The provider had failed to investigate this or report this potential neglect to the local authority safeguarding team to consider.

We saw a series of unwitnessed incidents including falls were recorded. The provider had not investigated these to consider if these needed to be reported to the Local Authority Safeguarding Team or to see how they had occurred. The incidents had not been reported as safeguarding concerns. The manager told us the PCS system had improved safeguarding as it had improved how incidents and accidents were reviewed and recorded. This meant this system had therefore not been effective in bringing about the changes the manager told us it had.

We observed people were not supported to transfer using the correct moving and handling techniques. We found these concerns at our last inspection, despite the provider telling us they had taken action to resolve this, which included training staff. Due to the nature of these concerns, we shared them immediately with the manager and 1 of the directors. However, despite this we saw a further incident of poor moving and handling. This placed people at an increased risk of falls and injury.

After our inspection we raised a safeguarding referral.

When needed we saw Deprivation of Liberty Safeguards (DoLS) remained in place for people, however we could not be assured these were up to date as care was not reviewed when changes occurred. The manager assured us these were up to date and they monitored these.

People and relatives raised no concerns around their safety. One person told us, “I feel safe here.” Another person told us, “There are people around at night which makes me feel safe.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe.

We received mixed feedback about how people’s risks were managed. One person told us they did not always have the correct staff to hoist them in line with their assessed needs. Another person told us, “I use a walking frame, and I can walk safely with it. They haven’t showed me where the lift is so I can’t get downstairs.” Other people felt their risks were managed well. One person said, “I do feel safe when they hoist me.”

At our last inspection we saw people were not supported safely to transfer, we told the provider to take action. At this inspection we again found the same concerns. We discussed this with the nominated individual who did not feel this was a reflection of how moving and handling was delivered in the home, they felt we had only observed a snapshot of care. However, our intelligence confirmed moving and handling was an ongoing concern in the home as since our last inspection, an external professional had raised a safeguarding concern when they witnessed further moving and handling concerns, which they described as unsafe.

We saw 1 person who was in bed and lying on a pressure mattress which was not switched on, we touched the mattress and it felt deflated. The person’s care records confirmed they were at risk of developing sore skin. We raised our concerns with the manager who turned on the equipment. We saw them feel the mattress and commented that it felt fine, despite it being deflated. The manager did not check the skin of this person to ensure it was still intact. This placed this person at risk of developing sore skin.

The provider told us they were in the process of moving records from paper to the electronic system. They manager us they had commenced using the system in May 2025. There were no plans in place to show how they were going to move effectively from paper to electronic records. They told us we may find some ‘teething issues’. We therefore gave the provider the opportunity to show us where the most up to date information was stored for people. We viewed both electronic and paper records as directed by the manger.

Care plans and risk assessments were not always in place, up to date or reviewed when needed. At our last inspection we had found the same concerns and told the provider to take action to ensure this information was in place. We found when people had fallen, left the home unsupervised or had a medical need, information was not always updated to consider how further risks may be mitigated.

Other people’s care plans were not always followed: for example, 1 person was supported to mobilise with 1 staff when their records stated they needed 2. When people required changes of position from pressure relief, records did not reflect this care had been provided in line with these plans. This all placed people at an increased risk of harm.

The care plan audits that had been introduced since our last inspection were not effective in identifying where care plans were not in place, not up to date or not reviewed, these audits had not identified the concerns we found.

The provider did not always detect and control potential risks in the care environment.

After our last site visit, we raised our concerns with the safety of the environment and told the provider to take action. We found some of the actions had been taken, this included the fitting of suitable window restrictors, removal of some furniture which was in a poor state of repair and doors which should have been locked were now locked.

However, we saw areas of the home that were unsafe and posed a risk to people, staff and members of the public. This included exposed radiators in communal bathrooms and hallways, a plug socket that was loose and coming away from the wall in the communal lounge, hazardous substances including Milton that was in communal hallways and loose wires that may pose as a trip hazard.

After our last site visit, we raised our concerns with the safety of the environment and told the provider to take action. We found some of the actions had been taken, this included the fitting of suitable window restrictors, removal of some furniture which was in a poor state of repair and doors which should have been locked were now locked.

The processes the provider had in place to monitor the safety of people’s environment were not effective in identifying areas of improvement, they had not identified the concerns we found at this inspection. After our last inspection we told the provider to take action as 3 radiators were exposed and were a risk to people. The provider acted on this and covered 2 of these radiators, we found on this inspection the third remained exposed. During feedback the providers’ response indicated they were not aware of this. The processes the provider had in place had failed to identify this, furthermore they had not identified that a further 2 radiators were exposed in a different part of the building.

After our inspection the provider told us they had taken action to resolve this, we will therefore review this as part of our next inspection.

In reference to the safety of the environment the provider told us they had, upgraded their Wi-Fi and phone systems, updated their car park and outdoor areas and changed the layout of the communal areas as recommended by the ICB. Although this may have improved people’s dining experience, they was no evidence to show how this had improved the environment or people’s safety.

People and relatives we spoke with raised no concerns to us about the safety of the environment.

We received mixed feedback on staffing. One person said, “When I ring my buzzer they answer it by saying they are busy but then don’t come back for up to half an hour.” A relative said, “I think there could be more staff.” Another person told us, “If I press my buzzer they answer it. I don’t have to wait.” A relative commented, “There does appear to be sufficient staff around when I have visited.” People and relatives raised no concerns around the knowledge and training of staff and felt they had the skills to support them safely.

Although on the whole we saw there were enough staff available for people, we did see at times some people had to wait for support.

Since our last inspection the provider was now using a dependency tool to monitor staffing levels within the home, they told us they were using more staff than the tool stated they needed. We viewed this tool that was completed on the 1 June 2025 and we could not be assured it was effective as the amount of people inputted into the document was 32 people, when there were 33 people living in the home. The tool was not due to be reviewed until 1 August 2025. Furthermore, as care plans, risk assessments and guidance had not always been reviewed or updated we could not be assured the information inputted into the tool was an accurate reflection of people’s needs.

Staff received some training to ensure they had the skills and knowledge to support people; the manager told us this had been reviewed since our last inspection. The manager also told us since the last inspection they had introduced a series of ‘in house’ training. We reviewed the training matrix, and this confirmed staff training was up to date. However, staff were not always competent to support people safely. For example, we observed poor moving and handling practices that placed people at risk of harm and staff and leaders were failing to identify potential safeguarding incidents.

Staff had received the relevant pre-employment checks before they could start working in the home to ensure they were safe to do so.

The provider did not assess or manage the risk of infection. They did not detect and therefore did not control the risk of it spreading.

We saw areas of the home that posed as an infection control risk. This included hand gel dispensers in communal areas that were either not working or empty. Face masks that were in communal areas had an expiry date of 2023. We found 2 clinical pedal bins were broken and therefore required you to touch them, a clinical waste bin that was overflowing and dead insects in a light fitting. We also saw a member of staff who was responsible for the management of food did not follow IPC guidance and demonstrated poor hygiene. We found areas of the kitchen were unclean and dusty. Food that we saw in the fridge also had to be disposed of as it was not dated. This all meant the provider had placed people, members of the public and staff at an increased risk of cross infection.

The processes the provider told us they had in place to monitor IPC were not effective in identifying areas of improvement, they had not identified the concerns we found at this inspection. We viewed the internal IPC audits completed by the provider; this covered the environment. Audits from both April and May 2025 had not identified any concerns with the environment and therefore were not effective.

The provider told us they had a phased refurbishment plan in place to improve the home. Although some actions had been completed, for example a new phone system, the concerns relating to IPC had not always been acted upon. At our last inspection we raised concerns as some pieces of furniture were an infection control risk, and they were in a poor state of repair. Although this furniture had been removed from the home, there was other furniture which had deteriorated since our last inspection and had not been replaced. We viewed the refurbishment plan which told us this would be acted upon by May 2025, as described this had therefore not taken place.

As reported upon under lessons learnt the provider had also failed to act on IPC concerns raised by the ICB and Local authority. The local authority also shared with us there had been several outbreaks in the home.

People raised no concerns with the cleanliness of the home. One person said, “Everywhere is nice and clean.” People also commented that their bedrooms were cleaned every day. “They clean my room every day”.

The provider did not always make sure that medicines were safely stored.

At our last inspection we found prescribed creams were not safely stored. We told the provider to take action. We found the same concerns and some prescribed creams were again insecurely stored in people’s bedrooms. Other people who were mobile could access these medicines, as the door to the rooms was open. During feedback the provider indicated they were not aware this had not been resolved. Therefore, the provider had to failed to act on previous concerns we had raised. We also saw the medicines trolley was left unlocked in the communal area where people were present. This therefore placed people at risk of harm.

The provider had introduced a medicines audit since our last inspection however it had not identified that medicines were not stored securely, as the audit did not reference whether creams were appropriately stored.

People were happy with how they received their medicines. One person told us, “I get my tablets every day. They bring them to me in a big cabinet.” Another person said, “I do get my medicine.”

Other improvements had been made to how medicines were managed. We found ‘as required guidance’ was now in place, stock checks were accurate, and people received their medicines when needed. Staff had received training in the management of medicines and their competency was checked. There was now also a clinical lead in post. The medicines audits introduced had identified other areas of improvement, such as when stock needed to be replaced.