Amber House Residential Home

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• 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.

This is the first assessment for this service. This key question has been rated 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 provider was in breach of legal regulation in relation to governance at the service.

This service scored 46 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The provider and deputy manager were working to promote a culture of openness, and was committed to ensuring the service was safe, effective, and a positive place to live for everyone.

However, the management team had not yet developed a full understanding of the needs of people using the service. The provider had only recently increased their presence at the service and with the deputy manager newly in post, a consistent practice and culture had not been embedded. Management did not have sufficient oversight of people’s needs, and staff reported struggling to carry out their daily duties due to feeling short‑staffed and under significant pressure. Care records were not developed to a level that accurately reflected each person’s needs.

As a result, the provider and deputy manager could not yet demonstrate that the values and culture they aimed to promote were being lived out in practice.

Both the deputy manager and the provider listened to the feedback we shared during the inspection, recognised the potential seriousness of the issues identified, and had begun to take steps to make improvements. The deputy manager said, “I want to ensure people live the best quality of life they can whilst they are here, we want to improve and get better.”

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not yet always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively.

Leaders had received training, but not always in a way that enabled them to effectively lead the service. The deputy manager had been placed into the role after the previous registered manager left and had been trying to lead well, but they were not fully equipped with the knowledge and experience needed to run the service confidently.

Staff had specific roles and responsibilities, but there was not enough oversight or managerial capacity to ensure staff had the right level of responsibility and accountability, or to ensure care tasks were carried out promptly and appropriately. Managers told us they understood the need for a more structured approach to support continuity of care and enable staff to work confidently and effectively.

However, the deputy manager was consistently visible within the service, and there was a clear commitment to making improvements. Staff told us they felt able to approach the deputy manager about day-to-day issues and valued their presence and willingness to listen.

People did not always feel they could speak up and that their voice would be heard.

People we spoke with said there were no formal ways for them to have their voices, views and opinions heard. They felt able to speak with staff, but not all staff had the authority to make significant changes, which limited how effectively their feedback could influence the service. People told us they would have valued regular residents’ meetings as a mechanism for sharing ideas and driving change.

We raised this with the provider and deputy manager, who said they would put this in place to ensure people had structured opportunities to contribute to the running of the service.

Staff told us they were generally happy to speak with the deputy manager and felt they would support them when concerns were raised. However, some staff said that when they raised issues with the provider, there was little change, meaning they often had to repeat the same information or manage situations as best they could. This affected staff confidence that concerns would be acted on promptly and effectively.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Whilst the provider and deputy manager were working towards a vision of creating an inclusive culture, there needed to be more structure around staffing, including how staff were supported to carry out their roles in line with the processes and practices set out within the service. Many of these systems still needed to be implemented or fully embedded. Staff required additional support to ensure there was equity across the whole team, and that everyone had the same opportunities, expectations and level of guidance.

For staff with diverse needs, these were taken into consideration, and some specific support and practices were adopted to help ensure their needs were met appropriately.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The systems in place to monitor and manage safety and quality across the service were ineffective. Due to changes in management, and with a lack of initial support and follow up by the provider, the appointment of a new deputy manager alone did not provide the oversight required. This led to a lack of understanding of the areas of improvement needed and the actions required to ensure the safe running of the service.

Despite the best efforts and commitment of the deputy manager, the support mechanisms in place were insufficient, meaning they were often learning as they went and did not have the full range of knowledge and skills needed to run and manage the service effectively with not enough structured support or provider oversight.

The provider had recently become more present within the service and had recognised the shortfalls, acknowledging that previous oversight had not been as effective as required. As a result, key elements of quality and safety management had been missed.

Some audits had been completed, but more recent ones did not consistently document who completed actions, what had been done, or when tasks were finalised. In several cases, records only contained generic notes stating that an action had been taken, which indicated there had not been enough time, support, training, or emphasis placed on the importance of audits and other governance tasks.

The provider and deputy manager were receptive to feedback, recognised what was required, and had begun developing plans to address outstanding tasks with the aim of improving quality and safety across the whole service.

The provider did not always collaborate and work in partnership, so services worked seamlessly for people. They did not always accurately share information and learning with partners or collaborate for improvement.

The provider and management team had working relationships with external partners, but they could not be reliably assured that they were always acting in people’s best interests, as the information held about individuals was not always up to date. This meant they could not be confident that the outcomes people experienced were the most appropriate, effective, or reliable.

The provider had some community connections, and external organisations such as singers and entertainers visited the service to support people’s social needs, but this required strengthening to ensure people had consistent and meaningful opportunities for engagement.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There had been opportunities for improvement across the service, but due to limited time, knowledge, and expertise, these were not always capitalised on, resulting in missed opportunities to strengthen practice and achieve better outcomes for people.

The provider and deputy manager had been engaging throughout the inspection process and were dedicated to improving the service. They demonstrated a commitment to making Amber House a better place to live and were motivated to address the shortfalls identified.