Amberley Hall 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 Inadequate. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was previously in breach of the legal regulation in relation to good governance and improvements were not found at this assessment, and the service remained in breach of this regulation.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The service’s values were embedded from the point of recruitment, reflecting the companies’ values in the application process through to daily life within the service and asking staff in daily meetings what values resonated with them that day. Staff are informed of the companies’ visions and values through staff newsletters and team meetings. The provider had clear processes in place for staff to follow.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty. We reviewed duty of candour letters that were issued to people when something had gone wrong when they had received care and support from the service. We were not assured that incidents were fully investigated and they were not always clear with the action taken. We were not assured the registered person understood their duty in applying duty of candour when a serious incident had occurred. However, the registered person was currently undertaking a further qualification to develop their skills and knowledge, and they felt supported by the provider. They responded to our feedback and put measures in place to address concerns raised where these had been missed in their auditing processes.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. The service had a clear policy and procedures in place for staff to follow and all staff understood this. A staff member told us, “To me, it means staff should feel safe and supported to raise concerns, share ideas, or report issues without fear of blame or unfair treatment.” The service did not always evidence clearly in staff meetings where they were encouraging staff to speak up however, there were notes made of actions taken. All the staff we spoke with felt they were able to raise concerns and would do so confidently and that when it involved people in the service it would always be actioned.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The service had a policy in place for staff around equality, diversity and inclusion. Reasonable adjustments were available for staff, supported by appropriate risk assessments for their roles or through flexible working arrangements. The service had a well-being champion that was implemented to support staffs’ wellbeing and discuss concerns on a weekly basis however, feedback from staff questioned the effectiveness of this.

The provider did not have effective systems and good governance. They did not act on the best information about risk, performance and outcomes. We found several issues within the environment that the provider had failed to identify, when we brought this to their attention, they implemented actions to resolve the issues.

The provider was not always following the most up-to guidance around managing infections and supporting people with UTI’s. Care plan audits that were completed did not consistently identify issues and appeared task orientated. They did not always find inconsistencies and assess risks around people’s care and support needs. Incidents were not always investigated fully, and referrals were not submitted to local safeguarding team where appropriate. Statutory notifications were not always submitted in a timely manner, and we found serious injuries were submitted 5 months after the incident. We had not had an updated statement of purpose from the provider since 2022.

However, the service submitted the updated statement of purpose when we made them aware, and they had identified issues with the current care planning software and were about to change to a new software at the end of our inspection.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Referrals to community partners were submitted in a timely manner, this evidenced a joined-up approach to supporting people’s care and support needs. The provider worked closely with the local community and had community engagements planned throughout the year. They had a community café that was held in the service once a month and encouraged emergency services to attend the service for some food and drinks to thank them for their committed work.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local systems. We found the service was in continued breach in some areas and were not assured that learning and improvement had been fully embedded throughout the whole service. However, the service had improved since the last inspection. Throughout this inspection the provider had been responsive and proactive in rectifying concerns we had found. They had improvement plans that were underway to improve the environment, to be more environmentally friendly and to improve their current care planning systems. They were currently participating in a dementia accreditation strategy to improve the dementia support provided within the service.