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 changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was previously in breach of the legal regulation in relation to
safe care and treatment. Not enough improvements were found at this assessment and the provider remained in breach of this regulation.

This service scored 53 (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 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.

Improvements had been made in the analysis of accidents and incidents, with systems in place to identify themes and trends. However, these improvements were not consistently embedded in practice. We found staff did not always complete observations of people following a fall in line with the provider’s own protocols. This meant there was a risk changes in people’s condition were not identified promptly. This was identified at our previous assessment, and the provider was continuing to take action to address this concern.

The provider had made improvements to their systems and processes and there was an emergent culture of learning in place within the service. The new systems and processes needed to be embedded and sustained into practice.

The provider did not always work with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Since the last assessment, the provider had made improvements in its working relationships with external healthcare professionals. Staff reported more consistent engagement with GPs, community nurses, and other relevant professionals. However, systems for sharing information with external professionals were not always robust or consistent. For example, we observed the registered manager did not have robust systems and processes to ensure the relevant information was shared with the GP during ward rounds.

Opportunities remained to strengthen information-sharing processes to ensure timely, accurate, and comprehensive communication, particularly in relation to changes in people’s needs. One visiting professional told us, “Reporting issues and wound care is not as good as it could be.”

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.

The provider had safeguarding systems and processes to ensure compliance with statutory requirements and protect individuals from abuse and neglect. Safeguarding records were maintained, documenting all incidents and the corresponding actions taken to mitigate future risks.

Staff had completed safeguarding training and understood what to do if someone reported abuse. They knew how to report concerns about abuse or neglect and were supported by clear policies and procedures. One staff member told us, “I have always been aware that if someone's welfare comes into question, we report it if concerned or see anything untoward.”

People can only have their freedom restricted for care and treatment if there is a legal process in place. In care homes, this is managed through the Deprivation of Liberty Safeguards (DoLS), part of the Mental Capacity Act 2005. The provider regularly checked and monitored these safeguards. Each person’s care plan included details about their capacity and any DoLS in place, explaining what this meant for their support.

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

The provider had made improvements to people’s care plans so information better reflected people’s specific care needs and were more person-centred. We did identify some areas where further improvement was required. For example, 1 person’s care records contained contradictory information regarding the application of bed rails to prevent them falling out of bed. We spoke to the management team about this, and they told us they were in the process of reviewing and updating all care plans. We recognised care plans had improved but there needed to be a continued focus on sustaining and embedding these improvements alongside robust monitoring, auditing and reviewing processes.

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

Robust systems were in place to ensure the home and its equipment were properly maintained and serviced. Regular checks were carried out, including scheduled servicing and safety inspections such as electrical compliance testing and fire risk assessments.

The provider undertook comprehensive risk assessments of the premises and implemented measures to ensure the safety of people, staff, and visitors. Individual Personal Emergency Evacuation Plans (PEEPs) were in place for each person, detailing the specific procedures required to support their safe evacuation in the event of an emergency.

The provider did not always make sure there were enough qualified, skilled and experienced staff.

Staffing levels were informed by the dependency needs of people using the service. During our assessment, staffing levels were in line with the assessed needs of the service. However, there was a heavy reliance on agency staff, and staff told us they felt more permanent staff were needed. One staff member told us, “We use agency quite often, some are very good, but some it’s there first time. We need more in house staff.”

The provider told us they were actively trying to recruit permanent staff, but this was proving challenging. Relatives shared concerns with us and told us they felt more staff were needed. One relative commented, “There was a big shift to agency people, they are pleasant enough but it’s not ideal, they don’t have time to go through care plans with agency people. I’ve spoken to the manager a month ago about it. They said they were trying to recruit their own staff.” Another relative said, “There were times when staffing levels could be improved, mainly at weekends.”

The provider undertook appropriate recruitment checks before staff started working at the service to ensure the suitability of staff before they commenced employment. These included obtaining references and Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. This helps providers make safe recruitment decisions.

The provider did not always assess or manage the risk of infection.

We observed the environment to be clean and tidy and domestic staff were routinely cleaning throughout our assessment. Cleaning schedules were followed effectively, and appropriate infection prevention and control risk assessments were in place and reviewed.

Care staff and domestic staff had the appropriate PPE available to them and were wearing it when required. However, we observed staff did not decontaminate their hands in between supporting people with their meals and medicines. Staff also failed to initiate appropriate infection control processes to prevent the potential spread of infection when a person experienced diarrhoea during the assessment.

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

Medicines were stored securely. Medicines that needed refrigeration were stored securely, with records of current, maximum, and minimum temperatures monitored daily to ensure their safe storage. Controlled drugs (CDs are medicines requiring more control due to their potential for abuse) were stored safely and securely, with access restricted to authorised staff and recorded appropriately.

During the medicines round, we observed staff administering medicines to people in a caring way. People were given their medicines, including time-sensitive medicines, at the right time to ensure that they were effective. However, a person was observed chewing their prescribed paracetamol tablet, stating that it was too large to swallow whole. The person had been on this medicine for 8 weeks. Despite this observed difficulty, there had been no documented review of the medicine's formulation, and the GP had not been consulted.

On review of medicine administration record (MAR) charts, we identified two separate incidents in which individuals were, on occasion, administered the wrong dose of their prescribed medicine. In both cases, the MAR chart indicated a dose of 2 tablets, but only 1 tablet had been given. These incidents had not been recorded as errors, and the home manager was unaware of them until they were brought up during the inspection. All medicines must be administered exactly as prescribed, and failure to give the prescribed dose must be reported as an error. This should be recorded appropriately so that appropriate investigation and learning can take place. During the inspection, several people's cover sheets in MAR folders were found not to match the corresponding MAR charts. Recorded allergies on the cover sheets did not always align with the allergy information on the MARs. This inconsistency could have led to errors. This issue, once raised, was addressed and corrected on the day of inspection. Cover sheets and MARs were updated to ensure that all allergy information was accurate and consistent.

On inspection, when reviewing notes, we observed that repeated medicine refusals by people were not consistently recorded in the medication notes alongside the MAR charts. In several cases, refusals were marked on the MAR but lacked corresponding entries in the daily medication notes explaining the reason for refusal or any follow‑up actions taken. One person routinely refused their prescribed midday dose of paracetamol. Although these refusals were recorded on the MAR chart, they were not documented in the medication notes, leaving no clear information about the reasons for refusal or the follow-up actions taken by staff. One person had not had their prescribed medicine for three consecutive days. These omissions in both people were not evidenced to have been escalated, and no GP or prescriber advice was sought to review the impact of the missed doses or assess whether an alternative plan was required. This does not follow safe medicine practice.

Two liquid medicines were found without a recorded opening date. This meant it was not possible for staff to confirm whether the products were still within their recommended shelf life. In addition, we found that some medicines with reduced expiry periods once opened had been labelled with incorrect expiry dates. The dates recorded on medicines did not reflect the manufacturer’s recommended shorter shelf life after opening. Staff should follow the manufacturer’s guidance and the provider's policy to correctly calculate and record expiry dates once medicines are used, ensuring they remain safe and effective.

Several people’s when required (PRN) medicines were found to be administered without supporting PRN protocols in place. For a variable-dose PRN medicine (e.g., 1–2 tablets), there was no written guidance in protocols to help staff decide whether to give 1 or 2 doses. This meant staff did not always have clear instructions on how and when to use PRN medicine.

Where medicines were given covertly (disguised in food or drink), we identified issues. For one person, a GP letter confirmed that covert administration had been authorised; however, the MAR chart did not indicate that the medicines were being given covertly. This created a risk that staff might not administer medicines in line with the agreed covert plan. For another person, the covert medication paperwork was incomplete. Several medicines were being administered covertly, but the corresponding documentation did not include directions for all of them, thereby failing to meet the best-practice requirements for covert administration.

Concerns were identified with the way entries were being recorded in the CD register. Several entries had been crossed out or overwritten rather than amended using the correct procedure. This is not in line with the legal requirements for maintaining CD records, making it difficult to ensure an accurate audit trail.