Archived: Amber House

Updated 8 April 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

Amber House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced although checks were completed prior to entry to ascertain COVID-19 status.

What we did before the inspection

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

We used all of this information to plan our inspection.

During the inspection

We spoke with five people who used the service about their experience of the care provided. We spoke with five members of staff including the provider and registered manager.

We reviewed a range of records. This included five people’s care records and multiple medication records. We looked at three staff files in relation to recruitment.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke with three care staff, and two relatives. We also liaised with the local authority and the community learning disability team.

Updated 8 April 2021

About the service

Amber House is a residential care home providing accommodation and personal care for up to 22 people with a learning disability, or autistic spectrum disorder. At the time of inspection, 15 people were using the service.

Amber house was registered for the support of up to 22 people. This is larger than current best practice guidance. The service consists of three buildings which have been combined. Two of the buildings are joined at ground floor level by a covered annex which serves as an entrance to all buildings. There is a small conservatory area, dining room, activity room, and a garden area that people can access.

People’s experience of using this service and what we found

The service had developed a closed culture under the current management structure, which placed people at risk of harm. Where people had experienced potential abuse, the registered manager had not informed key agencies to ensure investigations were undertaken and plans put in place to keep people safe.

Risks in relation to people's care was not always sufficiently detailed to ensure people were cared for in a safe way. There was not always accurate guidance in place for staff about how to manage or reduce risk.

The dependency needs of people were not considered to establish the required staffing levels to meet these needs. The deployment of staff did not account for people’s individual needs. Staff told us they needed more advanced training in managing behaviours that may challenge them. Other areas of training were overdue.

Care records were not always accurately detailed, or sufficient to ensure people's needs and preferences were documented. Documentation procedures did not enable staff to have effective oversight of people's care. This placed people at risk of harm. There was a lack of oversight and learning in relation to incidents and accidents.

People received their prescribed medicines, however, some documentation required additional detail where medicines were given 'as required'. Procedures needed to be more robust to ensure medicines were secured safely.

The provider's systems for monitoring and improving the quality of the service had not been effective. Issues identified at our last inspection remained and we identified further concerns. There was a lack of strong leadership, consistency and oversight at the service. Regulatory responsibilities had not been met.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. The model of care did not maximise people’s choice, control and Independence. Daily routines were designed to support the collective needs of the group, rather than deliver tailored care. This meant that care was not person-centred and did not promotes people’s dignity, privacy and human rights. The culture, values, attitudes and behaviours of leaders and care staff did not ensure people using the service led confident, inclusive and empowered lives.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 22 October 2019) and there were multiple breaches of regulation. The provider completed an improvement plan after the last inspection to show what they would do and by when. At this inspection we found improvements had not been made and the provider remained in breach of regulations.

Why we inspected

The inspection was prompted due to concerns we received about the failure to protect people from avoidable harm or abuse, poor staff culture and governance. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We found evidence during this inspection that people were at risk of harm. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Amber House on our website at www.cqc.org.uk.

Enforcement

Following the inspection we issued a Notice of Proposal to cancel the providers registration. The provider made representations which were not upheld. We subsequently issued a Notice of Decision to cancel the providers registration, and this service is no longer in operation.

The local authority worked closely with the provider to ensure people were supported to move into alternative accommodation.