Amber House - Coventry

Updated 15 April 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

This inspection was completed by two inspectors.

Service and service type

Amber House - Coventry is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Amber House - Coventry is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post. The provider had recruited a new manager for the service who intended to register with CQC.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was to ensure the provider or manager would be available to support the inspection.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with two people who lived at the service about their experiences of the care provided. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke to two relatives and an advocate of a person to gain their views of the support given. An advocate is a person who makes sure a person’s views and opinions are upheld when a person is not able to do this themselves. We spoke with five members of staff including the nominated individual, the manager and care staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider.

We reviewed three people's care records, multiple medication records, cleaning schedules, health and safety records, risk management monitoring forms, three staff files in relation to recruitment, staff rotas and records of quality assurance checks.

After the inspection

We continued to validate evidence found.

Updated 15 April 2022

About the service

Amber House - Coventry is a residential care home providing personal care to up to 15 people. The service provides support to older people, some of whom live with dementia. Accommodation is provided on two floors accessed by stairs and a stair lift. People have their own rooms with shared bathroom facilities and access to communal areas. At the time of our inspection there were 13 people living at the service.

People’s experience of using this service and what we found

Systems in place to monitor environmental and infection risks to people were not robust and placed people at risk of harm. The service was not clean, staff did not always wear Personal Protective Equipment (PPE) correctly and people were at risk of sustaining burns from uncovered hot water pipes. The provider took immediate action to rectify the issues we identified.

Quality monitoring was in place and a full range of audits were being completed for all areas. Whilst the monitoring was being carried out it had not identified all of the shortfalls we found during the inspection. The provider and manager had not ensured CQC were notified of all events they have a regulatory responsibility to inform us of. Following our inspection, the provider reviewed their quality monitoring system and made changes to make it more robust.

People and their relatives told us they received a good service and felt safe. Accidents and incidents were recorded, and risk assessments were in place. Staff understood their responsibilities about safeguarding and had been appropriately trained. Arrangements were in place for the safe administration of medicines.

There were enough staff on duty to meet the needs of people. The provider had an effective recruitment and selection procedure and carried out relevant vetting checks when they employed staff.

People, relatives and staff were asked for feedback about the service and for ideas on how to make improvements. People, relatives and staff spoke positively about the manager and the culture of the home.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 17 January 2020)

Why we inspected

We undertook a targeted inspection to review the service’s infection prevention and control procedures.

We inspected and found there was a concern with relation to the cleanliness of the service and environmental risks, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Following the first day of inspection the provider took action to mitigate the risk we identified. On the second day of inspection we found these actions had been effective to keep people safe.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Amber House - Coventry on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to the safe care of people and the governance of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.