Amberley Hall 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 requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was previously in breach of the legal regulation relating to safe care and treatment and staffing. On this inspection we found they were no longer in breach of these regulations. However, the service was previously in breach of the legal regulation in relation to safeguarding and improvements were not found at this assessment, and the service remained in breach of this regulation.

This service scored 53 (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 investigate and report safety events. We found incidents where people had developed unexplained bruising or skin tears that were not always investigated appropriately. Some instances were closed down as “cause of wound is unknown” and “it was unexplainable”. However, medical advice was always sought, and people’s relatives were informed. We were not assured of the accuracy of staff reporting of accidents and incidents. In 2 incidents, the provider informed us that the recorded accounts were not accurate descriptions of what had happened. The service had begun working with staff to address and improve reporting practices.

The service did create lessons learnt from other instances to identify and embed good practice. There was a clear process for staff to follow in relation to safety alerts and all staff we spoke with assured us with actions they would take following an accident or incident within the service. A staff member told us “Incidents are recorded and reviewed by seniors and management. We usually get feedback through handovers or discussions, and any learning is shared with the team.”

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. The provider ensured when people moved into the service that pre-admission assessments were conducted appropriately and these were then audited by management. Staff assured us how they were made aware of people’s health and care needs when they moved into service. A staff member told us, “Mostly from the care plan and from the relatives, power of attorney or from the person themselves if they can verbally express. At the start of every shift and end of every shift there is a handover and we give a handover of every person to the next shift.”

When people left the service, appropriate handover assessments were conducted to aid the transition safely and the service ensured everything was in place to protect the person from harm. The registered manager told us, “In relation to equipment the therapy team go with the person home to check what equipment they need. If equipment is not in place, the person stays here until it is in place. There is no standard practice in place, and we have to adapt to situations to ensure there is a safe discharge in place.”

The provider did not share concerns quickly and appropriately. We reviewed the services incident and accidents analysis and found several incidents that should have been reported to the local authority safeguarding team. Most incidents were of unexplained bruising or skin tears and investigations that were conducted were not always robust. We found when people developed suspected deep tissue injuries within the service or the environment that these were not reported.
During the inspection, 3 serious injury notifications were submitted to CQC that were from historical incidents involving 1 fracture and 2 head injuries and these incidents had not been reported to the local authority at the time they occurred.

We reported these concerns retrospectively and the provider investigated each case. The provider believed some of these did not meet threshold for reporting, although they were not assured until robust investigations were conducted several months following the incidents. There were some incidents that did meet the threshold. However, medical advice was sought where it was required, and relatives were informed of these incidents. Staff could tell us different signs of abuse, and this included unexplained bruising.

Where people lacked capacity and their freedom was deprived in order to protect them; the service ensured they had appropriate deprivation of liberty safeguards applications in place where applicable and those granted were reviewed and included within people’s care plans.

The provider did not always ensure staff consistently provided care to meet people’s needs that was safe, supportive and managed risks. We found instances where people’s care plans did not record how to manage risks associated with their care and support needs. One person’s care plan recorded in the event of a fire to take them to a lounge on another floor level this did not follow the services fire procedure. Another person’s care plan stated they needed to be repositioned by staff and the repositioning chart recorded the frequency of being supported to reposition. We reviewed the reposition chart and no frequency was recorded and there were entries of being repositioned ranging from 2 hours up to 7.5 hours. Another person’s care plan recorded how they took anti-seizure medication and had a history of seizures. They had no specific care plan informing staff what to do in the event of a seizure.

However, other people had robust risk assessments in place around their care and support needs. Staff could tell us the information recorded in people’s care plans and how that helped them to mitigate risks to people.

The provider did not always detect and control potential risks in the care environment. There were standing aids that belonged to the NHS and were part of the physiotherapists team. However, these were regularly used by the permanent staff within the service and there was no evidence they had been serviced. The provider acknowledged this and created a lesson learnt and shared it with the staff and all equipment was serviced and safe to use when we returned.

We found there was hot pipes exposed in communal toilets and 4 thermostatic mixer valves (TMVs) on taps had failed. These could scald people. The provider addressed these issues immediately and lagged the pipes and carried out a re-check of all their TMVs to be assured no others had failed and rectified the ones that had.

We found a person’s mobility scooter had a lithium battery on charge in a communal area, due to the associated fire risks, they should be charged in a designated separated area. The provider addressed this and when we returned to the service, it was being charged in a more suitable area.

We reviewed the fire risk assessment that was conducted in December 2025 and identified several fire doors had gaps around them and would allow a fire to spread through the building. These had an action on the risk assessment to be resolved within 2 weeks. These were still outstanding. During the inspection, the provider ensured the fire doors were resolved.

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. We reviewed staff recruitment records that showed safe recruitment processes were conducted prior to staff beginning their employment. Staff were inducted safely into the service, and their skills were assessed to ensure they were competent to meet the needs of their job role. Staff had the opportunity to develop, and several staff were in the process of gaining additional qualifications for their personal development.

We received mixed feedback from people and staff about the staffing levels. Some staff said “We are short staffed” and “probably in the morning there could be a bit more support”, while other staff told us “generally there is enough staff on shift unless someone calls in sick but when staff call in sick management will find the correct way to replace them” and “we always have enough staff for every community”. Staff told us the staffing levels had recently increased due to occupancy levels and the service had a dependency tool in place to assist in assessing the level of staff required.

The provider did not always detect infections and control the risk of it spreading or share concerns with appropriate agencies promptly. UK health security agency (UKHSA) has guidance for providers which recommends any linked respiratory infectious cases within a 14-day period of each other must be reported to them as a potential outbreak. Between September 2025 to March 2026, we found the service had a high number of upper respiratory infections in the service that were linked. These should have been reported to UKHSA and were not. We informed the provider of this, and they contacted UKHSA and implemented a lesson learnt. A clear outbreak poster for staff to follow and reviewed their procedures was implemented. All people that had respiratory infections received medical advice and treatment at the time. The service has plans to review this on a weekly basis going forward.

We observed there were wheelchairs in the service recorded as being cleaned but we identified they were still unclean and had a build-up of dust on the frames. The provider rectified this promptly when we informed them.

In general, the environment was clean, and people were happy with the cleanliness of the service. A person told us, “They keep everywhere clean and at least I don’t have to do it” and “the sheets on my bed are immaculately clean.”

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. We reviewed medicine administration and associated records for 11 people, observed staff giving people their medicines and we spoke with 3 members of staff. For medicines prescribed for occasional use at the discretion of staff (PRN medicines), information was available; however, guidance was not always sufficiently detailed. There was a lack of clarity regarding appropriate duration of use and when further clinical review should be sought, and this was not consistently reflected in people’s care plans.

There was also a lack of a clear overall strategy to guide staff where more than 1 medicine had been prescribed on a PRN basis for similar or related needs. This increased the risk of inconsistent or inappropriate use.

However, medicines were being stored securely and at appropriate temperatures. Records we checked showed people received their medicines as prescribed. Staff carried out regular checks of medicine stocks. Staff were regularly assessed as competent to manage and administer people’s medicines. We observed staff followed safe procedures when giving people their medicines.