Amber House Residential Home

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question [add rating]. At this assessment the rating has remained/changed to [add rating].

This is the first assessment for this service. This key question has been rated requires improvement. This meant people’s needs were not always met.

The provider was in breach of legal regulation in relation to person centred care at the service.

This service scored 43 (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 make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Wherever possible, people were spoken with directly about needs, wishes and preferences, but this was not a consistent practice, particularly for those who could not advocate for themselves and did not have anyone who could be regularly and legally consulted on their behalf.

Plans in place were not always completed fully or accurately, which meant staff were not always able to provide fully personalised care. Without detailed information, staff could not be certain they were fully addressing people’s needs, wishes and preferences.

The provider and acting manager acknowledged these shortfalls and were considering ways to adopt a more effective approach that would enable staff to update plans and get to know people more thoroughly. Some staff had specific responsibilities for updating plans, but they told us they did not have adequate time to complete this work. A holistic review and a new approach were needed to ensure people were fully assessed, plans and records were kept up to date, and staff were aware of everyone’s needs and preferences, so care could be truly personalised

There were very limited opportunities for people to engage in activities, and this affected how well their social and emotional needs were met. One person told us, “This place reminds me of being stuck in my old house, I feel penned in. They [staff] know I feel depressed. I want to go out in my wheelchair, but I feel it is too much for the staff.” A member of staff was working additional hours in the afternoons to provide some activities, but this was limited, meaning not everyone had the chance to take part in something important, meaningful or purposeful to them. They did however tell us, “For the activities, I will send a list to [name of provider] of everything I need, and they will just buy them. They are quite accommodating; they buy all the things needed for the activities.”

People who were able had access to books and newspapers, but this did not meet the needs of those who could not engage in activities independently. As a result, many people were left without stimulation and experienced periods of isolation, with few opportunities to enhance their wellbeing or maintain social connections.

One person said, “’I’m depressed as there is nothing here to do. I am either sitting watching TV or reading.” Another person told us they were unable to access the Wi‑Fi, which affected their ability to meet some of their social needs. We raised this with the provider on the person’s behalf, and they agreed to follow this up. Not having access to Wi‑Fi meant the person was missing opportunities to be more independent, including being able to spend time on their computer, which they expressed was important to them.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

People were not routinely asked, as part of the assessment process, whether they wished to disclose any protected characteristics or had any diverse health and care needs. This meant staff did not always have the information needed to provide inclusive, personalised support, increasing the risk that people’s individual identities, cultural needs or preferences were overlooked.

Sexuality care plans were not completed appropriately or in full, which meant staff did not have the necessary guidance to support people’s sexual identity, relationships or emotional wellbeing in a safe and respectful way. As a result, people’s rights to express themselves and maintain aspects of their personal identity were not always fully upheld.

The provider did support staff with diverse needs and gave examples of how they had supported staff from different cultures and those with specific religious requirements, enabling them to follow their faiths appropriately.

The provider told us they would take steps to improve, and were considering actions to strengthen oversight, ensure records were completed fully, and support staff to deliver more consistent and person‑centred care.

The provider did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Care records were not always detailed, up to date, or person‑centred. Records were not regularly reviewed or updated to ensure they reflected changes in people’s needs, preferences, or risks. As a result, information presented in accessible formats was not always relevant or accurate, limiting how effectively people could understand or engage with their own care.

There were, however, options for information to be provided in different and accessible formats where people needed this.

The provider did not always make it easy for people to share feedback and ideas, treatment and support. Staff could not always involve people in decisions about their care or tell them what had changed as a result.

Staff meetings were held and communication with management was generally viewed as satisfactory; however, feedback from staff was not always acted upon. Without consistent feedback and guidance, staff were not always clear about their roles and responsibilities. This reduced accountability and made it harder to identify learning when things went wrong, highlighting the need for clearer expectations and communication.

There had been a significant period of time since residents and relatives were last involved in meetings with the provider and management team. Several people currently living at the home were able to engage in discussion and could have been integral participants and advocates for others. They would have benefited from opportunities to share issues, concerns, and ideas in a structured forum. One person said, “I would really like a meeting so I could tell them [management] what I would like, and what could be done better.”

We raised this with the provider, who told us they would put this back on the agenda to ensure people had regular opportunities to contribute to the running of the service.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

Although people continued to receive the care they needed, it was not always as accurate or specifically tailored as it should have been because needs were not consistently reviewed and records were not always updated, which affected the reliability of the support provided. A process had already begun to strengthen reviews and improve record‑keeping so this could be addressed going forward.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care may not always be tailored in response to this.

Although there was no specific evidence of this occurring, there was a risk people were more likely to experience inequalities because staff did not always have the time to listen to people and their relatives to fully understand any barriers individuals faced and how these could be reduced. There was limited documentation about people’s specific needs, including protected characteristics, which meant care was not always tailored to each person’s needs and wishes.

The provider stated they would be making improvements to ensure people were able to express and communicate their preferences, so that support remained accessible, inclusive, and aligned with what mattered most to them.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

People had ReSPECT (Recommended Summary Plans for Emergency Care and Treatment) forms in place; however, some of these forms did not contain accurate information, which placed people at risk of receiving inappropriate care or treatment at the end of their lives. There were limited discussions and recorded details about people’s future care preferences, including their wishes relating to end‑of‑life care, meaning staff did not always have the guidance needed to support people in line with what mattered most to them.

The provider understood the importance of capturing this information to ensure people were appropriately supported at the end of their lives and acknowledged the need to strengthen practice in this area.