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 inadequate. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Improvements had been made to the culture and learning was now identified following incidents and events. Systems had been developed and embedded to ensure incidents were reviewed and analysed by the manager. Learning was taken from each event and actions were implemented to reduce the risk of reoccurrence.

The management team had used the findings from the last inspection to drive improvements across all aspects of the service. The manager told us, “We are seeing things in a different way. [Name of nominated individual] is challenging why we are doing things, all processes have changed.”

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Improvements had been made to ensure care plans and risk assessments were in place or reflective of people’s needs. People told us they had been involved in the assessment of their needs. One person said, “The staff know me well, I was involved in my care plan initially, I decide how I spend my time, when I get up and go to bed.”

The management team carried out assessments of people’s needs and worked alongside relevant professionals to develop care plans which offered guidance to staff about how to support people effectively. A relative told us, “My dad has only been here 2 weeks, when he arrived, the hospital had not fully told them what his needs were, the home have been great calling the hospital for information."

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe. One person said, “I feel safe here, because the staff are always around, it gives me reassurance.” Improvements had been made to the way the provider managed safeguarding events. The provider had established clear safeguarding processes and staff were aware of how to raise concerns for people’s safety and well-being. Incidents and events were reviewed and analysed to ensure any learning on how people could be protected from avoidable harm were recorded and shared with the staff team.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found that DoLS were applied for when necessary to ensure people who lacked mental capacity were lawfully supported.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Improvements had been made to the way risks were assessed and managed. People spoke positively about how staff supported them with specific aspects of their care, such as mobility. One person said, “There are always 2 carers when I need help in bed, either to be moved up to a more comfortable position or when I am hoisted into my chair. The staff know what they are doing, I don’t have any worries.”

We observed staff supporting people and saw this was done safely. Where people experienced times of anxiety or distress, staff understood their triggers and supported them calmly and with compassion.

Information about people’s risks, such as mobility, nutrition and hydration, skin integrity and specific health conditions had been assessed and guidance was available to staff about how to safely support people.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

People and relatives shared positive feedback about the safety of the home. One relative said, “The home is clean and tidy, I know I can leave here knowing my mum is well cared for and safe.”

Improvements had been made to the environment. The provider had introduced daily walkaround checks for staff and managers to check the home environment and ensure any maintenance issues were detected quickly so they could be addressed. Where concerns were identified, these had been recorded and actions taken to repair or improve the environment.

Ramps and adaptations to support mobility were in place, and basic signage was in place although there was scope for improvement in terms of clear directional or dementia friendly signage around the home.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People and relatives told us they thought staff had the skills and knowledge, or actively sought the information needed to care for them, and that there were enough staff on duty to meet their needs.

We carried out observations throughout our visit and found there were staff available both in communal areas and to support people who were cared for in bed. Feedback from relatives confirmed this.

Staff had received training to ensure they had the skills and knowledge required to meet people’s needs. One staff member said, “We have all completed medication and moving and handling training. We completed an induction with the manager, then shadowed experienced staff and we also have 1-2-1’s with the manager.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Improvements had been made to the management of infection prevention and control (IPC). Processes were now in place and staff were clear about their responsibilities to act if they noticed any concerns in relation to infection control. This included staff making regular checks on hand gel dispensers and dates on Personal Protective Equipment (PPE).

Monthly audits were undertaken by the manager and any concerns were recorded and addressed within appropriate timescales according to the risk posed. IPC was also included in discussions at daily staff meetings so staff could be informed of any required changes or updates.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. However, staff involved people in planning, including when changes happened.

We reviewed medication records and found stock counts for 1 person’s medicines did not match administration records. This meant we could not be assured this person received their medicines as prescribed. Processes for the return of unused medicines also needed to be improved to reduce the risk of error.

However, people told us they received their medicines as prescribed. One person said, “The staff give me my medication…I have never been forgotten or missed my tablets. The staff wear gloves and aprons at mealtimes and when the give out the tablets.”

When people used ‘as required’ medicines, clear protocols were in place to ensure these were administered consistently and when people needed them. Controlled drugs, which are subject to specific storage and recording guidelines were managed in line with good practice guidance.