Amberley House Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance.

This service scored 43 (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 have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider held a meeting in January 2026 with people living in the home to encourage the involvement of people. However, the information gathered during the meeting had not been used to drive improvement in ways that mattered to people. For example, people had stated in the meeting they were ‘sick to death of sponge and custard nearly every day.’ On the day of the assessment, we observed people were served sponge and custard and staff told us 1 person received custard most days. This meant the service had ignored the feedback.

The provider had not ensured the culture of the service promoted good outcomes for people. During mealtimes, the dining room was cluttered, people in the lounge were served at different times and staff did not always interact with people they were supporting with their lunch. People did not always receive care in line with expert advice.

Staff told us meetings had not been completed, and they could not remember the last staff meeting as it was “quite a long time ago”. This meant opportunities for leaders to share information and shared vision were missed.

Not all leaders understood the context in which the provider delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

The lack of effective systems and oversight of the care people received demonstrated a lack of capability within the management and leadership team. There was also a failure by all leaders to have adequate oversight of the staffing levels, staff training and people’s risks.

The provider had failed to notify us about all reportable events that had occurred in the service. For example, we saw documented evidence that people had received authorised Deprivation of Liberty Safeguards, and the registered manager had submitted a safeguarding concern to the local authority. However statutory notifications of these Incidents were not submitted to the Care Quality Commission. Providers must notify CQC of all incidents that effect the health, safety and welfare of people who use services.

People did not always feel they could speak up, and their voice would be heard.

The provider did not actively seek feedback from people and staff. The provider had not created opportunities for staff to raise their concerns in line with their own policy such as through regular team meetings and supervisions. Where people had raised concerns about the quality and variety of food on offer, no action had been taken to address people’s concerns.

Staff told us they did not always feel the provider listened to them. For example, 2 members of staff told us they do not see the registered manager “much” and had not met the nominated individual. One staff member told us, “It is hard at times, and depends on the type of staff you have got in, one day it’s been amazing, others you go home and you are frazzled”, they stated this was because of the staff, "skill set, people not doing it that long and people who don’t want to do the work.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff reported they did not feel discriminated against.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider’s auditing systems were ineffective and had not identified issues with the service’s performance prior to our assessment. Some planned audits had been missed and where audits were completed, they were ineffective. People told us they did not receive regular showers and records confirmed this. We discussed this with the registered manager who told us they did not audit this.

Monthly medication audits had been completed. The findings of the audit completed in March had identified gaps in recording on the medication administration records (MAR). These gaps included the amount of stock and recording of the rationale for why medication that was prescribed ‘as required’ (PRN) was given. The deputy manager told us this was an ongoing problem, and they had put a reminder note on the wall of the medication room reminding staff to record, “2 months ago”. In addition, the registered manager told us they had implemented a daily ‘Medication Round Accountability Sheet’ to address these failings.

We reviewed this document and found there was a free text box labelled ‘issues found’, this was blank. During the assessment we identified gaps in the MAR charts including stock amounts, and record keeping in relation to the use of PRN medications. This meant the action taken to mitigate further risk in response to the medication audit findings were ineffective.

We reviewed a care plan audit which had been completed for 3 service users. Where gaps had been identified, the ‘action required’ section of the audit was blank. This meant there was no evidence actions had been taken to ensure the care plans were reviewed and updated. During the inspection we reviewed 3 different care plans and found they were out of date and contained conflicting information.

The registered manager told us that although a dependency tool was available to assess and determine staffing levels based on people’s needs, it was not being used as they did not find it useful. We identified concerns in relation to staffing levels at night and the skills of the staff team available to support people. A staffing dependency tool would have helped the manager demonstrate staffing levels were appropriate.

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, and the manger was unable to demonstrate they had occurred. This meant there was no clear oversight or audit trail to demonstrate the manager had completed appropriate checks to ensure staffing levels were sufficient to meet people’s needs. 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 understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Records demonstrated guidance from professionals had not been consistently listed to or acted upon. This meant people were unnecessarily exposed to the risk of inappropriate or unsafe care.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider did not demonstrate oversight or implement action plans to continuously monitor and improve the outcomes for people. Auditing processes were ineffective and inconsistent. Some elements of the service were not audited. This meant opportunities for improvement and to address shortfalls had been missed.