Amber Court Residential Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of 2 legal regulations in relation to the governance of the service and the failure to notify us of incident that had occurred in the home.

This service scored 36 (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 shared vision, strategy and culture based on transparency.

The provider failed to work with openness and transparency, as incidents, which had resulted in injuries for people, had not always been investigated, the provider had not always shared information with local authority safeguarding teams or CQC. This demonstrated a closed culture within the service.

The values of the nominated individual raised concerns. They were not always receptive to information shared with them during feedback. When discussing risk, they told us they felt it was unfair for CQC to expect them to keep people safe all of the time. They told us they aimed to ensure people were safe 70% of the time. This approach taken by the nominated individual was of concern. It demonstrated the poor values of the organisation and raised concerns around the culture that was imbedded into the service and potentially shared with staff.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

There was no registered manager in place, the manager who was working in the home told us they were in process of registering with us. This provider is required to have a registered manager to oversee the delivery of regulated activities at this location.

The provider had failed to notify us about all events that had occurred in the service, in line with their legal responsibility to do so. We found since February 2025 there were at least 6 incidents where people had sustained injuries that we had not been notified about.

The lack of systems and oversight of the care people received demonstrated a lack of capability within the management and leadership team.

There was a failure by all leaders to have adequate oversight of the home. For example, when we shared the concerns about the cleanliness of the kitchen. The manager responded that it was due to be deep cleaned the following day, and did not acknowledge the potential risks posed by an unclean kitchen, this demonstrated a lack of credibility to lead effectively.

There was a lack of accountability from the nominated individual, they failed to recognise the seriousness of the concerns identified at the inspection. Despite the concerns raised from other professionals, the safeguarding concerns that had been identified from other professionals and visitors since our last inspection, the corroboration of evidence and the detail of concerns we provided in feedback, they described the inspection as a ‘bad day at the office’.

The culture of the service meant the provider failed to work transparently. The provider had failed to develop an open and honest culture where they worked openly with people, their families and other professionals to share concerns.

The provider had failed to notify us about events that had happened in the service including ‘major injuries’. They had also failed to investigate and share safeguarding concerns, to ensure people were protected from potential abuse or harm.

Staff told us they felt confident and comfortable to raise concerns and there was a whistleblowing policy in place that staff were aware of and the procedures they needed to follow.

The provider valued diversity in their workforce.

Staff felt they were treated in an inclusive way and their needs were considered. There were policies in place to consider staffs’ individual needs and plans to ensure this was effective.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Some audits had been introduced since our last inspection; however, they were not effective in keeping people safe, identifying concerns and driving improvements through the service. For example, a medicines audit had been introduced, this had failed to identify prescribed creams remined insecurely stored, meaning this audit was not effective.

Other audits including spot checks that had been introduced and the manager’s walkaround, had again failed to identify and act upon concerns we found at this inspection and that we have reported on throughout this report. This included concerns with the environment, IPC concerns, and audits had failed to identify concerns around the competency of staff. Audits had not identified a pressure mattress was switched off, and the provider’s own records showed this should be checked daily, but we saw checks had only been completed 3 times in June. We also found there was no detailed analysis of incidents and accidents to ensure action had been taken and trends identified.

There remains a lack of oversight and people continue to receive unsafe care. Since our last inspection the provider had introduced an audit of people’s care plans and records, this had failed to identify people’s information was incorrectly being added to the PCS system and that care records were inaccurate and out of date.

After our last inspection we raised our concerns around the governance of the service, we told the provider to take action. At this inspection we again found the same concerns. The systems the provider had introduced had not been effective in making improvements to the home and the care people received, which had resulted in continued breaches of the legal regulations.

The provider told us the initiatives they had implemented were designed not only to, meet current standards but also to build a foundation for continuous quality improvement, ensuring that both residents and staff experience a consistently high standard and a supportive, engaging environment. As reported on throughout this report this meant this system had not been effective in bringing about the changes the provider told us it did.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people.

The provider stated they worked in partnership with other agencies to deliver care to people. They stated ‘we have been working very closely with the Wolverhampton Council Quality Assurance Team and the Integrated Care Board (ICB). We have had recent inspection visits from the local authority, ICB, and infection prevention teams, during which no major concerns were raised, and all actions were completed satisfactorily’. We viewed the information the Local authority and ICB had shared with us about the home, which showed us there were ongoing concerns within this service and areas for improvement. The provider had failed to acknowledge and share the concerns external agencies had shared with them, they had also failed to act on some these areas of which meant people continued to receive unsafe care and treatment.

There remained no effective systems in place to ensure they worked in partnership with other agencies, as there was a lack of up-to-date information and oversight of people’s care. When changes occurred, information was not always documented.

There was a lack of effective systems in place to identify concerns and drive improvements, which meant learning opportunities were missed.

The provider told us since the last inspection they had introduced a suggestion box, where people and relatives could share ideas. Two suggestions raised concerns around the cleanliness of the fish tank that was in the home. Although the manager told us this was to be resolved soon, we saw the fish tank was unclean. Furthermore, we discussed this with the local authority who told us they had previously shared their concerns with the provider about this and the potential risk to people.

Other suggestions had been acted upon including action to ensure visitors could access the home more promptly.

The providers told us ‘we took over the management of Wellesley House Nursing Home less than a year ago and have been diligently working to implement improvements and address outstanding issues’. They felt it was important to note that the majority of the issues raised during the last CQC inspection in November 2024 were pre-existing concerns. We found there remained no effective systems in place that ensured concerns were identified and acted on. There had been a deterioration in rating, continued breaches of regulation and new breaches of regulations since the provider and their directors took control of Wellesley House Nursing home. This meant learning, improvement and innovation were not promoted.