Amber Rose Healthcare Ltd

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.

This is the first assessment for this newly registered service. This key question has been rated good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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 that promoted inclusion and openness. Staff described the service as having an “open door policy” and said managers encouraged questions and feedback.

People and staff felt listened to and valued. There was evidence of team meetings and opportunities for reflection on practice. The culture was described as, “It feels like a family here”, and compliments from families highlighted kindness and dignity in care.

There was good communication across teams, with handovers and diaries ensuring continuity. The provider could strengthen formal feedback processes for people using the service, as current feedback is mostly informal. One relative commented, “I phone the manager or email her, and she always gets back to me. When I am visiting, I quite often see [registered manager’s name] there. I haven’t been asked for formal feedback, we just have informal chats.”

The provider understood the context in which they delivered care and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders were visible and approachable. Staff consistently reported that managers were supportive, helpful and praised good practice. The registered manager was known to people and families and was described as responsive to calls and emails.

Staff told us there was always a senior member of staff on call who they could contact at any time for advice or support. One member of staff said, “It is drummed into us, always pick up the phone and call. Whatever happens we are open and transparent."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff told us they felt comfortable raising concerns and were confident issues they raised would be taken seriously. There was a clear safeguarding process, and staff could escalate concerns to senior managers, the local authority or CQC if needed. Comments such as “Not afraid of speaking up if there is a mistake” and “Manager is open” were common.

Team meetings and supervisions provided further opportunities for staff to share ideas and concerns.

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.

Staff from different backgrounds spoke positively about feeling valued and respected. There was evidence of reasonable adjustments being considered.

Training compliance was high, and staff were encouraged to progress through qualifications.

The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Governance systems were in place to monitor quality and safety. Audits were completed for various aspects of the service including care plans, incidents and medicines. However, some audits lacked detail about what was checked. As this is a small service at the present time, this did not have a negative impact on the care and support people received. Following the site visit the registered manager shared changes they would be making to ensure audits were more robust and would lead to further improvements for people using the service.

The registered manager had oversight of care records through the electronic care plan system and took action where risks, such as falls, were identified.

Staff files showed induction, training and probation reviews were completed.

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.

The service worked with external professionals, including physiotherapists, occupational therapists and district nurses, to support people’s health and independence. Care plans showed involvement from psychologists and other specialists. People were supported to access community activities and holidays, and staff adapted care plans to reflect changing needs.

The provider focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

There was evidence of a learning culture. Staff meetings included opportunities for reflection and suggestions for improvement. The provider responded to incidents and complaints by implementing changes, such as clearer visitor procedures after a professional raised a concern. Training records showed high compliance, and staff felt supported to develop skills.