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 inadequate. At this assessment the rating has remained as 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 people’s safe care and treatment, infection prevention control practices, and the way people’s medicines were managed.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Leaders were unable to demonstrate they had learned from previous incidents and failings. At our last inspection, we identified serious concerns with people’s safety and shared the findings with the provider to enable them to learn and improve. At this inspection, the provider had failed to make improvements, and significant areas of concern remained. For example, people were still observed to be sleeping on mattresses that were malodourous and had urine staining inside the cover. This was identified at the last inspection, and the provider had given assurances this would be addressed in December 2024.

Incident records, usually relating to distressed behaviour from people living at the service, still did not identify the primary need of the behaviour or ways to reduce the likelihood of the incident occurring again. This was raised at the last inspection. The failure to support people in the most appropriate way for their needs meant staff had been harmed by people living at the service.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Concerns were raised about the exchange of important health information. A relative stated, “The communication about the mental health team visiting is poor, I don’t know the outcome or that they have been, it says on [loved ones] file that I should be told. I have [Power of Attorney]. I am hopeful they will do it now.”

Some medicine records were not recorded accurately, and this meant the provider would not have accurate information to share with health professionals if they came to visit the people who lived at the service.

When people expressed a choice to avoid hospital admission, the provider worked with them and health professionals to try to respect this choice.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

People were exposed to a risk of harm due to the provider’s failure to report incidents in a timely manner. One matter had recently been reported as a safeguarding concern to the local authority team, however the person’s behaviour had been ongoing for some time before this was reported.

Several 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 ensure compliance with this, including meeting any condition which may have been imposed at the time of authorisation.

We identified multiple people living at the service who had conditions attached to their DoLS authorisation. Whilst the provider had met some conditions, there were still some conditions which had not been met. We identified the same concern at our previous inspection. This meant the provider failed to operate within legal requirements, and this placed people at risk of not having their human rights protected.

One person had a DoLS condition which stated the care provider must complete mental capacity assessments for specific areas of care, however the provider had not completed all of the required assessments. This placed the person at risk of experiencing unnecessary restrictions in some aspects of their care.

Another person had conditions in place to state they required a consistent programme of social activities to prevent social isolation, however we saw evidence their activities were offered erratically and were not consistent. For 1 week, the person had been offered activities each day, however there was then a 10 day period where no activities were recorded as being offered. This meant the provider could not demonstrate they had adhered to the person’s DoLS conditions, and placed the person at risk of social isolation.

The provider’s failure to ensure compliance with DoLS conditions was also identified at the last inspection. This meant people were still at risk of being restricted without the correct legal authority.

The provider had a safeguarding policy in place, and the training matrix showed staff had received training.

The provider did not work well with people to understand and manage risks. 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 still not managed effectively. This had been identified as a concern at the last inspection.

We reviewed a person’s care plan which described how they were at risk of skin breakdown. They had previously had pressure sores develop and these had healed. However, staff had not completed repositioning in accordance with the person’s care plan, and this had caused their pressure sore to reoccur.

Two pressure relieving mattresses were set to the wrong weight for the person sleeping on them, which placed the 2 people at increased risk of skin breakdown.This was identified as a concern at our last inspection.

We observed a person to be in one area of the home and their walking frame to be in a different area, which increased their risk of injury from falls. This was identified as a concern at the last inspection.

A person who displayed sexualised behaviour to other people did not have a risk assessment in place until this was raised by inspectors during the inspection, despite this being a known risk which had been identified by a DoLS assessor. There had also been an incident of the person using graphic sexually inappropriate language towards another person living at the home some months before the inspection. At this time, no risk mitigation measures had been put in place by the provider.

The provider told us they had done a lot of work on improving risk assessments across the service since our last inspection and that these were now being reviewed each month by senior care staff. Unfortunately, a number of documents we looked at still contained inaccurate or out of date information about people’s care needs.

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

We raised significant concerns about the environment, particularly in relation to mattresses, at the last inspection and were given assurances from the provider that action would be taken to rectify the areas of concern. However, when we returned to complete this inspection, we observed some of the new mattresses which had been ordered after the last inspection, to again be stained with urine and have a strong odour. We observed multiple other issues including 2 pressure cushions with urine stains inside, rust on a shower chair, debris and staining on 2 armchairs, food remains on a person’s specialist chair, faecal stains on a sling used to help a person mobilise, and a stained pillow and quilt inside clean bedcovers. Some people’s bedrooms were also malodourous.

At the last inspection, the provider had been encouraged to define job roles for care, maintenance and housekeeping staff, to ensure responsibilities regarding cleaning and sanitising items were clear. When we spoke with staff at this inspection, they were still unclear on whose responsibility each task was, and this meant tasks were not always completed, leading to equipment in the service being unclean.

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.Some areas of the service, such as the dining rooms, reception and activity room were clean and tidy.

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

The provider had a dependency tool which had calculated the number of care staff required on each shift. Rotas showed the figures on the dependency tool had been met. However, a number of the issues identified at this inspection related to there not being sufficient numbers of staff for people’s specific needs. Inspectors observed a person requiring support to get to the toilet, however, there were not enough staff available at the time to help them because staff were supporting other people. This had left 1 member of staff on their own in the lounge with multiple people. The people sitting in the lounge could not be left unattended, and therefore, the remaining staff member was unable to support the person to get to the bathroom in time, resulting in the person experiencing incontinence.

Two incidents where staff had been harmed by people living at the service were recorded after they had experienced long waiting times to be helped to the toilet.

People were not repositioned in a timely manner and this had contributed to a person’s pressure sore reoccurring.

Another person was observed walking with purpose without staff supervision where medicines for other people had been left unattended by staff. This put them at significant risk of accessing medicines not prescribed for them.

Feedback from relatives demonstrated concerns over staffing levels. One relative said, “I go in [to visit] and the lady doing the medication is being pulled to [help with mealtime]. I think the medication is important and that should be her only job.” They then went on to say, “Sometimes only 1 staff on. Staff seem stretched.”

Another relative was asked if they felt there were sufficient staff on to meet their loved ones needs. They replied, “Probably not, [staff are] a bit thin on the floor, especially at breaktime. Sometimes it is difficult to find staff.”

Based on our finding at this inspection, the provider’s dependency tool had not correctly identified people’s needs or staffing levels.

Staff compliance with training had improved since our last inspection.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. There were numerous incidents throughout the inspection where we observed infection control processes not adhered to and the risk of cross contamination not managed.

We identified the clinical waste bin area unlocked in the car park on multiple occasions and this meant it was accessible to the public. Inside the bin store area was very untidy with used gloves littered on the floor. We raised this with the management team, who locked the area, however the area was then found to be unlocked again later in the day. This was raised as a concern at our last inspection.

People were at increased risk of food poisoning because opened food in kitchenette fridge’s were unlabelled, which meant staff could not be sure the food or drink was still safe to serve to people.

People were at increased risk of contracting Legionella disease, due to the build up of limescale on some taps in ensuite bathrooms. We understood at the last inspection, a planned programme of works was being undertaken with a water treatment company, however when we spoke to staff, they believed tap descaling was supposed to be completed inhouse, although were not clear whether this was their responsibility or the responsibility of another team within the service.

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

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

The provider told us they had received support from their in-house pharmacy specialist for a number of weeks to make improvements following our last inspection. However, we found people were still at risk of harm through their medicines being administered unsafely or incorrectly at this inspection.

Medicine administration was not fully observed, meaning drinks containing medicines were left unattended by a staff member and accessible to other people living at the service. This meant people living with dementia or reduced capacity were at an increased risk of consuming medicines not prescribed to them.

Where medicines had not been administered, the reason for this had not always been recorded so it was not clear whether these medicines had been missed by staff completing the drugs round.

Where staff members had written new medicines on to medicine charts, a second staff member had not always signed to confirm they had reviewed this. This was important to ensure the accuracy of the transcription and to ensure no mistakes had been made prior to staff administering the medicine to the person.

Where people had ‘when required’ medicines, protocols to support staff to administer these correctly were not clear or contained incorrect information, placing people at risk of receiving the wrong dose.

A relative told us recently there had been an issue in their loved one receiving their anti-psychotic medicine as the provider believed the medicine had been stopped, however this had turned out to be incorrect and meant the person had missed some doses of their medicine.

Therefore, the provider had not followed their own medicine policy to ensure the risks associated with alterations to medicines were mitigated and failed to protect the wellbeing of people.