Ambar Care Ltd

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 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 service was in breach of legal regulation in relation to safe care and treatment. People did not always have up to date care plans and risk assessments in place that matched their needs. People’s medicines were not always managed safely.

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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. The registered manager reviewed accident, incidents and safeguarding concerns and shared any learning with staff through meetings and briefings.

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.

The system in place for people moving between services was not always robust. The registered manager told us when they first accepted a care package, they do not always have time to do an initial assessment and are reliant on information they received from other referral information or phone calls. The registered manager explained that they usually met people for the first time when they commenced the first care call. Following this call the registered manager informed staff of the care requirements but clear written guidance was not implemented immediately. The registered manager informed us this could take a couple of days to put in place a care plan.This meant staff did not have clear guidance on how people preferred to be supported, their risks or preferences from the outset of care being provided. By not completing an initial assessment this also placed people at risk of the service not being able to meet their needs effectively.

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.

Staff had received training in safeguarding and knew how to raise concerns. One member of staff said, “I would make sure the person is safe from harm and not being abused or neglected. I would follow the company policy and report to my manager first.”

The registered manager had raised safeguarding concerns appropriately and worked with the local authority safeguarding team to provide safe outcomes for people.

People told us they felt safe with the support staff provided to them. However, we found that care records did not always contain up to date information and guidance for staff on how this should be achieved safely. For example, where some people required support with mobilisation using a hoist, risk assessments and guidance for staff were not in place. Information for the management of catheter care was not provided to staff and where some people had diabetes there was not always clear guidance on how to support people who may have an episode of high or low blood sugar levels. This meant that we were not assured staff had all the information they needed to support people safely.

We found care plans did not always match the needs of people being supported and risk assessments were not in place. This placed people at risk of not receiving safe care.

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.

Although people were supported in their own homes, we did not find any detailed risk assessments in place to guide staff on what to do if there was an issue within the person’s environment. This left staff vulnerable to using faulty equipment or appliances and not having guidance in place of what to do if there was an environmental issue.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide care that met people’s individual needs.

People told us they were supported by a regular team of carers. One relative told us, “We have 4 calls a day with 2 carers. Since Jan 2026. One main person who's consistent, we've got to know the other staff. They are all very good.” Another relative said, “We have the same carers.” Staff confirmed they had a regular rota which they were given in advance of working.

The registered manager completed employment checks before staff began working at the service. This included obtaining references, right to work and up to date disclosure and barring checks (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer and help employers make safer recruitment decisions.We found the registered manager had not always recognised where staff had gaps in employment or confirmed with them, what these gaps were for.

Staff told us they were given an induction to the service which included working with experienced members of staff. Training was supported and this included face to face training to develop staff skills in specific areas of care and their competency to do this was checked. All staff were supported with 1:1 supervision at regular intervals and spot checks were completed of their work to ensure they were maintaining standards.

The registered manager held regular staff meetings and kept staff updated with briefings and newsletters.

The provider did not always assess or manage the risk of infection. We found guidance on infection prevention control (IPC) was not recorded in people’s care records or risk assessments. However, staff had all received training in IPC and told us they had access to personal protective equipment when they needed it.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We found where people were supported with the application of creams these had not been added to medication administration records (MAR). We also found a lack of risk assessments and guidance in place for staff to follow. This meant there was no clear, accurate or accountable record of the medicines being administered, increasing the risk of errors and reducing assurance that people received their medicines safely.

We were not assured medication audits in place were effective as they had not identified issues we saw with transcribing errors on one person’s MAR chart. Medication audits were completed monthly which meant there was a delay in identifying errors and learning from mistakes.

All staff had received medicine training and had their competency to support people with medicines checked.