Amberley House Care Home

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 regulations in relation to people’s safe care and treatment, governance, safeguarding and staffing.

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.

Lessons were not consistently learnt to continually identify and embed good practice. Incidents and identified risks were not used effectively to improve practice, and people remained exposed to ongoing and avoidable risks.

The provider’s systems for identifying, reviewing and embedding learning were ineffective. Reviews of people’s needs did not reflect current risks or changing circumstances, as highlighted within the ‘involving people to manage risk’ quality statement. Care plan audits had failed to identify inaccurate and incomplete risk assessments, indicating that audit systems were ineffective in identifying concerns or driving improvement. As a result, lessons were not learned and necessary actions were not taken to reduce risks to people.

Although action was taken following a recent incident in which staff had failed to notify a healthcare professional when a person had not opened their bowels for 10 days, learning was not embedded into practice. The registered manager had implemented a ‘bowel management protocol’ following that incident. However, this had not been effective, as staff had not followed this when a further incident had occurred. This demonstrated learning from incidents was not reinforced, monitored or sustained, and there was no effective assurance that changes to practice were understood or consistently applied by staff.

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 make sure there was continuity of care.

We found some care plans could not always be relied on to guide the safe delivery of care. Records contained conflicting and inaccurate information, which increased the risk of harm. For example, one person was known to be at risk of falls. However, this was not reflected in their risk assessment. Meaning staff did not have accurate guidance to manage the risk effectively.

Professionals reported concerns that their specialist advice was not consistently followed, and they were not confident that people were receiving care that reduced the risk of further deterioration to their physical health. For example, a healthcare professional had provided clear guidance on the volume of fortified fluids required for a person at risk of malnutrition. Although daily food and fluid records were completed, the professional told us they could not determine how much the person had actually consumed when they had reviewed the records. This lack of accurate record keeping made it difficult for professionals to make appropriate clinical decisions. As a result, systems for ensuring safe care planning, information sharing and professional oversight were ineffective, and people could not be assured they were receiving care that consistently reflected their assessed risks and professional guidance.

The provider did not have effective systems to ensure people were protected from avoidable harm, abuse or unlawful practice. Staff did not consistently understand or apply the principles of the Mental Capacity Act, restrictions were not appropriately recognised or authorised, and management oversight was insufficient. As a result, people were not adequately safeguarded, and the service was unable to provide assurance that people’s rights and freedoms were respected.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA).

We assessed whether the service was working within the principles of the MCA and how DoLS were managed. The service had completed necessary capacity assessments and applied for DoLS authorisations for some people. However, we found the registered manager had not maintained accurate records of where DoLS authorisations had been granted.

The registered manager provided a spreadsheet used to monitor DoLS applications and authorisations. This record was inaccurate and did not provide reliable oversight. In several instances, the spreadsheet recorded restrictions as authorised when, in fact, the local authority had only acknowledged receipt of the application, and no authorisation had been granted. This meant the service could not be assured that people were not subject to unlawful restrictions, and governance systems were ineffective in monitoring compliance with the DoLS requirements.

In addition, we identified one person’s rights and freedoms were being unnecessarily restricted. During the assessment this person was supported to eat a lunch time meal that consisted of soft food with pureed meat. We reviewed their nutrition and hydration care plan, dated 7 April 2026 which detailed guidance provided by a healthcare professional that clearly stated the person was able to eat food of normal consistency. However, daily food records showed the person routinely received pureed meals, and the chef confirmed they were providing a soft diet and puree meat. This demonstrated staff were not following professional guidance and a DoLS application had not been submitted in relation to this restriction. This placed the person at risk of having their rights restricted unlawfully and without appropriate safeguards.

A safeguarding referral was made by the CQC for this person following the assessment, which included concerns the service was unlawfully restricting the person’s rights and freedoms and were not providing care that met their needs, including poor skin integrity management and diet and nutrition monitoring.

Safeguarding concerns were not always reported by the provider. One person had not had their bowels open for 10 days and the service failed to seek medical advice. A safeguarding referral was made by healthcare professionals in February 2026, and the manager implemented actions to reduce further occurrences.

Financial management of people’s money held within the service was regularly audited by 2 members of staff. Records showed all transactions were recorded and the amount of money in the service tallied with the records.

The provider did not work well with people to understand and manage risks. Risks were not clearly identified, reviewed, or communicated, people were not supported to understand or manage risks relating to their care, placing them at risk of unsafe care and treatment.

The provider did not effectively assess and manage risks to people’s health and safety. Care plans, risk assessments and handover information contained conflicting and inaccurate information and did not give clear guidance for staff. This meant people were not properly involved in managing risks, and staff were not directed to provide care safely.

For 1 person, records relating to their mobility and falls risk were inconsistent. A mobility care plan stated the person was unable to walk, while a falls risk assessment completed on the same day described them as independent. Daily handover information stated the person walked with a stick. The person had sustained a fracture following a fall, this information was not included in the risk assessment. These inconsistencies created a risk that staff would not understand the person’s 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

At the time of the assessment, the dining room was not being used by people. Some stored items, including plaster boards were leant against a wall, boxes of continence products that had recently been delivered were temporarily located in this area, and the refrigerator required cleaning. We spoke with the registered manager who told us this would be addressed.

The environment was visibly clean, tidy and warm. Records showed health and safety checks were carried out frequently. Care equipment, such as moving and handling aids were serviced and maintenance records kept.

During the assessment, external water testing was being carried out as part of routine monitoring to ensure potential risks were identified and managed.

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.

During the assessment the registered manager and staff told us there had been an increase and ongoing use of agency staff, some of whom may have been unfamiliar with people and the service. A member of staff explained there was, “not a great mix of staff today. Two agency [members of staff], one’s been out of care for a few months and not been here before”. This meant staff did not always have adequate knowledge of people’s needs and preferences.

We reviewed the staffing records and spoke with staff. Staffing levels and skill mix varied significantly day to day, with new, inexperienced, and agency staff often forming the majority of the staff team.

A dependency tool was available to assess staffing levels based on people’s needs. However, the registered manager told us this was not being used.

We observed delays in staff response times to call bells, including one person waiting 15 minutes for assistance. Staff told us response times and quality of care was dependent on the “skill set and people not doing it that long”. Staff were not consistently present in communal areas, and a person was observed calling for help without support.

At night, staffing levels consisted of 3 care staff and 1 registered nurse to support 33 people. Staff told us that 11 people required support from two staff members to assist them with personal care and mobility. This meant when 2 staff were supporting 1 person in their bedroom, the remaining 2 staff were required to monitor and support all other people across the service. This staffing arrangement increased the risk of delays in responding to call bells and providing timely care and support to meet people’s needs during the night.

People and their relatives told us staff were generally available to support them, although they said there were occasions when they had to wait. One person told us the timeliness of responses to call bells “depends how busy they are, but I’m ok with that”. This indicated that people did not always receive timely staff support, particularly when staff were not present in communal areas.

The registered manager told us they completed daily walkabouts throughout the service and spot checks were undertaken during the night. However, these checks had not been recorded. This meant there was no clear oversight or audit trail to demonstrate staffing levels and deployment were effective, and opportunities to identify and respond to any risks or impact on people’s safety and care may have been missed.

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

Staff had received infection prevention and control training, and personal protective equipment (PPE) was readily available throughout the service. However, staff did not always follow the provider’s infection control and prevention policy and procedures. During the assessment, we observed 1 member of staff carrying an open bag containing soiled laundry without wearing gloves or an apron. When this was raised, the deputy manager acknowledged that PPE should have been worn.

We also observed medication administration practices that did not fully align with the infection prevention control standards. One nurse did not wash their hands before administering medicines, between supporting individuals, or after administering eye drops. This increased the risk of cross contamination.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The provider’s medication policy and procedure were not followed by staff.

We reviewed medication administration records (MAR) charts for medication prescribed to be given ‘as required’ (PRN). We found staff were not recording when a person had been offered and had refused these. When staff had given a PRN medication, they had not always written on the back of the MAR chart why they had been given. The deputy manager confirmed this should be recorded to ensure medicines were used appropriately and their effectiveness monitored. PRN protocols were not always completed to direct staff on why the medication should be administered and how often.

During the assessment we heard 1 person call out, “Help…hurts”. We reported this to the nurse on duty. The person was prescribed medication to be used continuously which had been given, but also 2 further pain-relieving medications to be given ‘as required’. The MAR charts for both medications, which we reviewed later in the day, contained no record to show whether prescribed PRN pain relief had been offered, administered or refused after the person had expressed, they were in pain. This meant the person was exposed to the risk of experiencing unnecessary pain as prescribed pain relief was not offered when requested.

The provider’s medication policy required staff to count medicines and accurately record the balances. However, during a medication administration observation, we identified several gaps where this had not been recorded. A medication audit had been completed prior to our assessment and identified gaps in recording and stock control. Action taken included placing a reminder note in the medication room and implementation of a daily review of the MAR. Additional daily audits had been implemented. We reviewed these records and found the daily audits had not recorded the omissions which had been identified during the assessment. This meant actions taken to improve recording were ineffective, and people may not have received their medication as prescribed.