The Amwell

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 good. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to the management of risk to people living at the service; the safe management of medicines; preventing and controlling the spread of infection and ensuring that staff delivering care or treatment to people had the qualifications and skills to do so safely at the service.

This service scored 28 (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 ensure a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

A number of relatives raised concerns with us during the assessment about the safety of their loved ones.

A relative recounted an incident which had occurred when another relative had visited their loved one. They said, “[Other relative] walked into [family member’s] bedroom and found this man in my [family member’s] bed and my [family member] sitting in a chair near him saying that he needed to leave. [Other relative] spoke to [staff member] at the time who was crying and saying that she felt that she'd let my [family member] down but that she hadn't got the staff to follow this male resident around. I later had a phone call from the care home to say that the police had been involved but then I've heard absolutely no more about it.”

Incident records, usually of behaviours that challenge between people living at the service, did not identify the primary need of the behaviour. This meant future incidents could not effectively be prevented as staff had not understood the root cause of the original incident.

Most accidents such as slips, trips and falls had been logged at the time of occurrence and had a good amount of detailed information.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not ensure continuityof care, including when people moved between different services.

Concerns were raised about the communication between staff members. One relative told us, "There doesn't seem to be a handover from one set of staff to another. I can spend the whole afternoon there and [family member] could be having all sorts of appointments with the visiting doctor and the next day when I go in to talk to the senior on duty that day about it, they often know absolutely nothing about it.”

The provider failed to ensure effective processes were operated by staff when a person became unwell. A Local Authority contract monitoring visit in October 2024 identified medical attention had not been sought for a person who had become unwell with a medical emergency, which had negatively impacted the person’s long-term health.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

A number of people living at the service did not have capacity to be able to consent to their care and treatment, and therefore, a Deprivation of Liberty Safeguards (DoLS) had been applied for by the service and granted by the Local Authority. Where a person has a DoLS in place, the provider must take certain steps to ensuring compliance with this, including meeting any conditions which may have been imposed at the time of authorisation.

We identified 4 people with conditions attached to their DoLS authorisation, however, not all these conditions had been met. One person required staff to provide clear records and a detailed description of how staff responded if the person refused to accept support with personal care, to ensure they could monitor the person’s needs and wishes and the effectiveness of any care interventions. The person had refused this support on 6 occasions over a period of time, and staff had recorded the intervention as 'declined’ with no further information. Another person required a risk assessment to ensure particular risks to their safety had been properly assessed and mitigated, and the provider was given 2 weeks to complete this. The provider took 5 months to complete the risk assessment which exposed the person to a prolonged period of increased risk of harm.

Two people were found to have expired DoLS authorisations , and 1 person’s DoLS authorisation was due to expire during the assessment period. However, there was no evidence these had been reapplied for. This was raised with the interim deputy manager, who completed 1 renewal application, and advised they would work on the others.

The provider had a safeguarding policy in place, and the provider’s training matrix recorded that most staff had completed safeguarding training.

The provider did not work well with people to understand and manage risk. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks related to people’s skin integrity and pressure area care were not managed effectively. We reviewed a person’s care plan which described they were at risk of skin breakdown. However, there was insufficient guidance on how to support the person to safely reposition with an active pressure sore. Staff also failed to reposition the person in a timely manner.

Another person’s pressure relieving mattress was set to the wrong weight, which meant it was not correct for the person’s needs and placed them at increased risk of skin breakdown.

On the first day of the assessment, we observed 2 people to not have their mobility equipment within reaching distance. This was escalated to the turnaround manager who advised they would complete a full review and address all mobility equipment issues. On the third day, we observed sat in armchairs with walking aids on the opposite side of their bedroom. This meant, if people wished to mobilise independently, they could not reach their walking aid, and this placed them at increased risk of injury from falls.

Another person was observed in their recliner armchair with the overbed table so high, they were at risk of spilling their drink as they could not reach this easily.

The turnaround manager was open and honest with us on the first day of the assessment and advised from the reviews they had commenced in the 1 week they had been in post, people did not have sufficient risk assessments in place. They were creating an action plan and this included reviewed all people’s care plans and risk assessments to ensure they were accurate and reflective of their needs.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We identified multiple concerns with equipment across the home. We observed ingrained dirt in wheelchair handles, stained mattresses, stained pillows and duvets, a ripped cover on a crash mat, a stained pressure cushion, rust on a shower chair, malodourous bedrooms, debris and staining on a communal lounge chair, and the carpets within the main areas of the care home had a noticeable unpleasant smell.

We raised these concerns with the turnaround manager, and they immediately escalated the concerns to the provider, and within 2 hours, came back to inspectors to advise they had ordered brand new mattresses for every bed, new pillows and duvets for every person at the service, new bedding and new pressure equipment. They also confirmed some areas in the environment requiring improvement had already been identified and actioned prior to the assessment, such as all carpets were to be deep cleaned. This deep cleaning of carpets was observed during the course of the assessment.

Staff told us that prior to the turnaround manager joining the service, they had never been told by the provider to complete mattress checks.

The layout and design of the service was suitable for the people who lived there. Corridors and doorways were wide enough for people who required mobility aids to move about freely.

The provider did not ensure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

Feedback about the numbers of staff was poor. One relative said, “Residents are left in the lounge without any member of staff present and I've witnessed lots of arguments between residents and I've even been chased by a resident.” Another told us, “When I walk in the corridors there is always someone crying out for help and no staff go. And it's not because they don't care but just because they don't have enough staff.”

Relatives shared concerns about the effectiveness of staff training. One relative said, “We don't feel all the staff are qualified in the jobs they're supposed to do, for example with medications.” Another stated, “We have asked whether all staff received mandatory training but have had no response to a question. About 60 to 70% of the staff don't appear to follow the mandatory training if they have had it.”

Gaps in staff training records indicated some staff had not received required training to meet people’s needs safely.

Concerns were raised about the professionalism of staff. A relative said, “[Staff] talk to other people in front of anybody about their private lives, but they don't talk to the residents.” Another said, “One day my [other relative] and [my family member] walked back from having gone out onto the floor of the care home and heard the staff talking negatively about them. In a public space – the staff were moaning about us all.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of infection spreading or share concerns with appropriate agencies promptly.

We identified the clinical waste bin area unlocked in the car park accessible to the public. Inside the bin store area was very untidy with used gloves littered on the floor. The provider acted quickly when we shared these concerns, and the bin area was cleaned and locked.

We also identified used cardboard urine bowls being left in a communal toilet, which people living with dementia and their relatives could access. We raised these issues to the turnaround manager who removed the items and disposed of them.

Some waste receptacles within the care home were found to below the expected standard. For example, 1 bin located in the sluice had remains of bodily fluid inside and was extremely malodourous. Another had a broken foot pedal, meaning staff had to touch the bin lid each time they wished to dispose of anything, which impacted on their ability to prevent cross-contamination.

A number of ensuite bathroom taps had a build-up of limescale on them, which harbours bacteria that can lead to legionella. We spoke with a representative from a water treatment company who advised they were working closely with the provider on a planned programme of works.

Most people and relatives felt that the care home was clean and well maintained, however 1 person reported a strong smell on a particular floor.

Relatives reported staff generally looked professional and wore a uniform.

Staff had an adequate supply of Personal Protective Equipment (PPE) such as disposable gloves and aprons.

The provider did not ensure medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

People were at risk of harm through their medicines being administered unsafely or incorrectly.

We identified some prescription items which were out of date. Medicine room temperatures and fridge temperatures exceeded the recommended range on multiple occasions, which meant the effectiveness of medicines may have been impacted.

A number of gaps were identified on people’s medicine administration record (MAR) charts. This meant it was not clear people had received all of their prescribed medicines.

A significant number of post-administration medicine counts completed by senior care staff and nurses were incorrect. Errors had continued for a period of days, which meant senior care staff and nurses had not completed physical counts of the medicines.

Relatives reported issues with their family members receiving their medicines. One stated, “One of the issues which has happened several times is that [my family member's] medications have been messed up.”

The turnaround manager had already identified a significant number of issues with medicines and was working hard to rectify these and implement new, safe, practices. A pharmacy specialist from within the provider had also been providing intensive support to the service and we were advised this would continue until all medicine issues had been resolved.