- Homecare service
Amber Home Carers Surrey
Assessment report published 4 March 2026
Contents
Ratings
Our view of the service
Date of Inspection: 28 October 2025 to 19 November 2025.
Amber Home Carers Surrey provides personal care to people in supported living settings and older people living in their own homes. This report is in relation to the supported living settings, which at the time of our assessment were provided across 9 separate locations. During our assessment we visited 5 of those settings. The service is also registered to provide treatment for disease, disorder or injury. However, the provider told us they were not utilising this part of their registration. There was a registered manager in post who was also the Nominated Individual for the service. They are referred to as the provider throughout the report.
The assessment was carried out to review reports of concerns regarding people’s care, including their safety, the management of incidents, safeguarding, staff skills, and the maintenance of their dignity. During our assessment we identified breaches of legal regulations in relation to managing risks to people’s safety, medicines management, providing person centred care in line with best practice, treating people with dignity and respect, staff skills and knowledge and the overall governance of the service. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choice, independence, and good access to local communities, which most people take for granted. We found both the management and staff teams lacked understanding of this and other best practice guidance. This meant people’s needs, preferences, aspirations and outcomes were not reviewed in line with the guidance, and they were not supported to have as ordinary a life as possible.
Risks to people’s safe care and treatment were not robustly assessed, and there was a lack of guidance for staff to follow. Care plans lacked essential information about people’s individual needs, such as how their anxiety presents, what triggers distress for them, and the specific strategies that help to support them. Accidents and incidents were not consistently reviewed, and there was limited evidence that appropriate actions were taken to reduce the risks identified. We identified in excess of 40 cases where safeguarding concerns were not reported externally in line with required procedures. This lack of oversight meant that people and staff did not receive timely support or opportunities to learn from incidents, which contributed to an environment where concerns were not openly recognised or addressed.
There was a lack of guidance regarding people’s health care needs. Staff were not always aware of people’s health care conditions, the support they required to manage them or when referrals to healthcare professionals should be made. Systems to manage people’s medicines safely were not robust and records were not reviewed to identify concerns.
People’s support was not effective as systems and processes were not implemented to ensure robust assessments, support planning and review. Complaints and concerns were not recorded to enable trends to be identified and issues to be reviewed.
Although staff told us they felt supported in their roles, we found there was a lack of structured guidance and supervision to monitor their practice and ensure they received the training they required. There was a lack of overall governance with no audits being completed in areas including medicines, care records, staff management, safeguarding or accidents and incidents. This meant that shortfalls in the care and support people and staff received had not been identified and acted upon.
Following our assessment the provider assured us they had completed a review of the systems in place and had implemented a range of processes which they considered would improve the service people received.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
People's experience of this service
We received mixed feedback from people and their relatives regarding the support people received. Some relatives told us they felt the service did not listen to the views of their family members and did not feel the staff or management team had the skills required to support them safely. While other people’s relatives expressed general satisfaction with their care, our assessment found care did not meet the expected standards.
People did not receive the support they needed to manage their emotional distress or associated risks. We observed staff did not know how to support people to reduce or de-escalate incidents. This led to some people experiencing periods of tension and feeling unsafe in their homes. Staff did not demonstrate an understanding of people’s needs or preferred communication styles which meant they were not fully involved in making decisions regarding how they wanted to be supported.
There was no evidence that people were supported to set goals, express their aspirations, or plan for activities that were important to them. Care records did not show that people’s quality of life had been explored or assessed with them to understand what mattered most in their daily lives. Staff were not familiar with people’s life histories or personal backgrounds, which meant this information was not used to build an understanding of individuals or their emotional needs. Although people were supported to go out regularly, records and observations showed limited flexibility in how activities were planned or how people were supported to make choices about the things they enjoyed.
People’s dignity, autonomy and privacy were not consistently upheld. The living environments did not promote privacy, and we found examples where staff did not demonstrate an understanding of people’s right to confidentiality. Although we observed some interactions where staff were kind and respectful, this was not consistent across the service.
People did not always receive their medicines in line with the prescriber’s guidance which placed them at significant risk of harm. We found medicines that were out of date, not in stock when required or not recognised by staff responsible for administering them. Although people were supported to attend health appointments there was no system to track referrals, monitor health information or ensure follow-up actions were completed. Staff were not aware of the purpose of health information for some people, and some were unclear about when or how to seek urgent medical assistance. This meant people were at risk of not receiving timely or appropriate healthcare.