Ambercare (North west) 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to 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 71 (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. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Managers demonstrated a positive, compassionate and listening culture. Staff spoke positively about the support they received and the culture of the service. Comments included,“I have been at Ambercare for 6 months now and although I have worked at other care companies I can confidently say that Ambercare is one of the best care companies that I proudly work for” and “As a carer at Ambercare, I truly appreciate the supportive and caring atmosphere fostered by the management. I feel valued and listened to, which makes for a positive work culture.”

There was a policy on equality, diversity and inclusion. Staff all received training in this topic. People, their relatives and staff were encouraged to provide feedback on the service to help shape its future. People and relatives told us, “We get asked for feedback regularly. I would recommend the agency. They have made my life a lot better” and “I have filled out a survey, a hundred percent I would recommend this company.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment 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.

The service had an established management structure in place. Staff praised the provider, registered manager and the wider management team. Staff spoke positively about the support they received. Staff told us, “Staff are encouraged to put forward ideas and suggestions, and these are actively listened to and considered by management”, “The service is managed well. [Provider and registered manager] are great and easy to get on with” and “[Managers] are both really good and approachable.”

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

People and their relatives told us when they raised concerns with their care and support they were addressed. They felt able to speak with management and staff should they need to. Comments included, “I have made a complaint [and it was dealt with]”, “I have built up a really good relationship with them [managers] and I think the agency is well managed” and “[Managers] are very supportive.”

The service demonstrated a positive, compassionate and listening culture. Staff and leaders acted with openness, honesty and transparency. The service had a whistleblowing policy in place. Staff we spoke with told us they felt able to speak up about any issues and their concerns would be listened to and acted upon.

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.

The provider had systems in place review and investigate accidents, incidents and safeguarding concerns. Staff managed accidents and incidents safely; first aid support was provided where needed, medical support and advice was sought, and management were kept updated. Systems were in place for recording and analysing any trends and implemented changes in response to any lessons learned.

Staff reported an open culture where they were encouraged to report all concerns. They told us,“[Manager]” will always action concerns or if they couldn’t, they will find out how to” and “If I had any concerns, I would inform the office straight away, they [managers] deal with such situations promptly.”

People and their families told us they could raise concerns about their care and knew who to speak to. They told us, “I would ring or email them [managers] if I had any concerns” and “I know how to [raise concerns].”

Governance systems were in place to monitor the standard of care people received, however, recording systems for audits required improvement. Regular audits of people's care plans, medicine records, daily logs, and staff recruitment files took place, and these audits were recorded by the care co-ordinators. However, the provider also audited peoples’ care plans and associated risks, taking necessary action to improve records where needed, however, these audits and action plans were not always recorded. The provider assured us they will be implementing a recording process for these audits.

We found the provider had failed to submit 2 statutory notifications to the CQC. Registered providers have a duty to submit statutory notifications to the CQC when certain incidents, such as serious injuries or allegations of abuse happen. The provider had managed the incidents appropriately and raised safeguarding referrals with the local authority as required. The provider submitted the relevant notifications to the CQC retrospectively during the inspection process. The provider was aware of their duty to notify and we found other statutory notifications [such as allegations of abuse and expected deaths] had been submitted to the CQC as required.

The provider had clear responsibilities, roles, and systems of accountability. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes. Feedback from staff confirmed information was used to monitor and improve the quality of care and best practice guidance were used to help improve the safety and quality of care people received.

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.

In our review of people’s care records, conversations with the registered manager and staff, we found the provider was in contact with relevant health professionals to ensure people’s needs were met in a timely way.

Feedback from external health and social care professionals were positive, we were told the provider communicated well.

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

Processes were in place to ensure learning happened when things went wrong. They also shared examples of good practice to support further learning. The provider had implemented learning from the last CQC inspection, and the service had made improvements. People’s care records were detailed, staff supervisions were conducted regularly in line with the provider’s policy, accidents and incidents were recorded and analysed for trends, and medicine records were improved.

The registered manager sought guidance and advice following our feedback regarding their own responsibilities in submitting relevant statutory notifications to us.

Feedback from people and their relatives were sought through regular contact, surveys and quality monitoring to drive service improvements. We found feedback from people was positive and any negative feedback were followed up.