Amber House Residential 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 requires improvement. The provider was in breach of legal regulation in relation to people’s safe care and treatment and safe and effective staffing. Enough improvement was found and the provider was no longer in breach of this legal regulation. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.
 

This service scored 69 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Since the last inspection, the provider had worked hard to make significant and sustained improvements, which had positively shaped the learning culture within the service. By adopting a new approach and seeking appropriate support and guidance, safety events were more clearly recognised and reported in a timely manner. Staff demonstrated increased knowledge and confidence in the reporting and recording processes, which had contributed to the overall improvements in safety.
 

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.

By improving care‑planning processes and strengthening the key documents which supported people’s assessed needs, the provider created continuity of care for people moving into and out of the service. These improvements meant staff had clearer, more consistent information to guide safe transitions. The provider and management team worked closely with partner agencies to build on this progress, ensuring people experienced smoother, safer and more coordinated pathways of care.
 

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe using the service. One person said, “I do feel safe, the staff are really good.” Relatives and staff were consistent in their feedback, confirming they also felt people were supported safely and appropriately. One relative told us, “Yes, I do think [relative] is safe here.”

Safeguarding processes across the service had improved significantly due to staff developing a stronger and more consistent understanding of their responsibilities. Staff had received further training and were clearer in describing what constituted a safeguarding concern and how they would report it. As a result, safeguarding procedures had become more robust, enabling concerns to be identified, escalated and managed in a timely and appropriate way.
 

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People’s risks were managed well because staff had a clearer and more consistent understanding of people’s needs and because of improved, accurate and more detailed documentation. Risk management plans were in place which outlined the specific risks for each person, along with the actions staff should take to support them safely and in line with their wishes and preferences.

People also had individualised health plans, such as for those living with diabetes or those requiring catheter care, ensuring their needs were met safely and in a timely way. A staff member said, “We do have risk assessments in the care plans and they do get updated.” Another staff member said, “I read the care plans, and our seniors tell us when there have been any changes.”
 

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

There had been significant improvements to the environment to ensure people could live in a safe and hazard‑free setting. For example, windows were now fitted with appropriate restrictors in line with guidance, and the home was less cluttered and free from trip hazards. The provider had invested in making physical changes to the service to reduce risks wherever possible. Relevant professionals had been consulted to obtain expert advice on how to enhance safety and ensure improvements were effective and sustainable.

There were still some outstanding actions required by the fire safety service; however, the provider was working collaboratively with them to ensure immediate risks were addressed. Longer‑term and more substantial improvements were being planned and completed within agreed timeframes to ensure compliance and maintain a safe environment for people.
 

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

Although there had been many improvements with staffing, this remained an ongoing area of development. Overall, staff told us they felt happier and that morale within the service had improved. Training had improved, and staff were now in receipt of regular supervisions. However, some staff felt there were still further improvements that could be made to support them in their roles, which in turn would help them provide even better support to people.

Some people using the service had increased needs since the last inspection, and several staff expressed concern how this reduced the time available to complete other tasks due to higher levels of dependency. The provider used a dependency tool to assess staffing requirements, and this was due to be reviewed, particularly now people’s documentation was more accurate and reflective of their current needs. One staff member said, “Sometimes, it can be more difficult in the evenings; we have not got that many residents here at the moment, but when we do, we will need more support.” Another staff member told us, “Staffing is okay because we haven't got as many residents right now. We have got a lot more residents that need hoisting now so sometimes it can become stressful because for that we need 2 staff.”

The provider explained that while improvements had been made, opportunities to increase staffing levels had been limited due to previous suspensions and the lack of new admissions. As improvements continued to be recognised and more people were able to move into the service, staffing levels would be reviewed, with the expectation an increase would be required to meet people’s needs safely and effectively.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The cleanliness of the service had improved, supported by environmental changes such as enhanced storage and better organisation of communal areas. The premises were clean, odour‑free and staff were seen implementing effective cleaning practices during the inspection.
Some structural limitations remained due to the age of the building, and certain areas required repair to enable more efficient cleaning. These actions were included within the provider’s ongoing improvement programme.
 

The provider did not always ensure medicine records were kept updated to reflect people’s treatments. Medicine quality controls needed to be improved to monitor records.

There had been notable improvements in medicines management, supported by enhanced processes and strengthened staff competency. Staff received additional training, and the provider worked with external agencies to embed safer and more effective medicines practices. This contributed to improved assurance that people received their medicines safely.

However, some gaps were identified in medication administration records. The care support manager was able to demonstrate medicines had been administered as prescribed and the omissions reflected documentation errors rather than missed doses. This highlighted the need for further controls and oversight around recording practices, and the provider planned to follow this up with staff to ensure documentation was consistently accurate and reliable.