Amber Home Carers Surrey

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• Overview
• Kindness, compassion and dignity
• Treating people as individuals
• Independence, choice and control
• Responding to people’s immediate needs
• Workforce wellbeing and enablement

Caring – this means we looked for evidence that the provider involved people and treated them with compassion, kindness, dignity and respect. At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate.

This meant people were not treated with compassion and there were breaches of dignity; staff caring attitudes had significant shortfalls.

The service was in breach of legal regulation in relation to the lack of privacy and dignity afforded to people, people’s care not being person-centred and shortfalls in the governance and oversight of the service.

This service scored 35 (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 ensure people were treated with kindness, empathy or compassion, nor did they uphold people’s privacy and dignity.

Although some people and relatives spoke positively about individual staff members, one person told us, “They are really nice and helpful. I like all the staff”, and a relative commented staff “seem to love (family member)” these views did not reflect the wider culture or the experiences we observed. While examples of kindness were seen, this was not consistent across the service and did not mitigate the significant concerns identified.

In several settings, we found serious and unacceptable failures in how people were supported. These demonstrated a lack of empathy, respect, and basic regard for dignity. In one setting, the bathroom used by two people was located directly off the main lounge, requiring individuals to walk through a communal space to access it. We observed a staff member leaving the bathroom door ajar while a person was using the toilet, despite another person, three staff members, and an inspector being present in the lounge. This was a clear breach of privacy and showed disregard for the person’s dignity.

When the person came out of the bathroom, they were visibly distressed. The staff member supporting them offered no reassurance, comfort, or compassion. Instead, they responded in an authoritative, directive and undignified manner, worsening the person’s distress. Later, when the individual requested a glass of water, they were told on two occasions they must sing a song before being allowed a drink. This was demeaning, disrespectful and entirely inappropriate, demonstrating a fundamental lack of understanding of dignity, autonomy and human rights.

Following our assessment the provider made adaptations to the lounge area to ensure people could use the bathroom in privacy.

We also found systemic failings in maintaining confidentiality and respecting personal information. In three different settings, we observed personal and sensitive information about people’s needs, health contacts and support requirements displayed openly on noticeboards in communal areas such as lounges and kitchens. The wording used was disrespectful, unprofessional and insensitive, indicating staff did not understand or value the importance of confidentiality. This demonstrated a pattern of poor practice replicated across multiple settings, not an isolated oversight.

The provider did not treat people as individuals or ensure their care, support and treatment reflected their needs, preferences or personal histories. The service failed to take account of people’s strengths, abilities, aspirations, culture, unique backgrounds and protected characteristics. People’s life histories, experiences and identities were not considered when planning or delivering their support. Important information about who people were, what mattered to them, and experiences that shaped their lives was either missing or recorded superficially within care plans. Staff we spoke with were unable to describe basic aspects of people’s backgrounds, including where they had lived, key family relationships or events that had shaped their wellbeing. As a result, staff did not have the knowledge required to provide meaningful or personalised support.

We observed the impact of this in practice. One person referred to a distressing event from their past, something they regularly spoke about and clearly carried emotional weight. Staff supporting them did not acknowledge their distress, respond with empathy, or offer reassurance. Staff later told us they were unaware of the significance of this event, despite it being a recurring theme for the person. This lack of awareness meant staff were unable to provide appropriate emotional support or recognise triggers that affected the person’s wellbeing.

Care records also lacked essential details about people’s likes, dislikes, communication preferences, and what was important to them in their daily lives. This created barriers to build trust, develop meaningful relationships or support people in a way that reflected who they were as individuals. It also meant staff could not encourage people to maintain or develop interests, build on their abilities, or engage in activities that were personally meaningful.

The cumulative effect of these failings was that people received generic, task‑led care, rather than support that recognised them as individuals. The absence of personalised information in documentation, combined with staff’s limited understanding of the people they supported, showed this was not an isolated shortfall but a system‑wide failure across the service.

This demonstrated that the provider had not embedded a culture of person‑centred care, resulting in people’s needs, preferences and identities being overlooked.

The provider did not promote people’s independence or uphold their right to choice and control over their own care, treatment and wellbeing. As a result, people were not empowered to make decisions about their daily lives or supported to understand their rights. While some people and relatives told us they enjoyed certain aspects of their routines, one person said they liked how they spent their time, and a relative commented that their family member “thrives” on going out daily, these isolated examples did not reflect consistent good practice across the service. Another relative told us, “They go on a lot of drives rather than doing anything. At reviews there are always promises of setting things up like college, but it never materialises.” This demonstrates a culture where people’s aspirations were discussed but not acted upon, limiting their opportunities, growth and personal development.

We found significant restrictions on how people spent their time, with decisions largely driven by service routines rather than individual choice. People’s daily activities were dictated by when transport and drivers were available, rather than based on what people wanted to do or when they wanted to do it. The provider told us they believed people “benefitted from going out most days” and arranged drivers to facilitate this, but there was no evidence that people had meaningfully chosen these activities or that their preferences had been explored.

Each person had an “activity board” outlining their daily routine; however, these were produced without evidence of the person’s involvement, and records did not reflect genuine choice. We saw that what was recorded on activity boards often did not match what actually happened, and records rarely showed how people had been supported to choose what they wanted to do. This meant people experienced repetitive, inflexible and provider‑led routines, rather than personalised, responsive support.

We identified a clear example where a person expressed a preference that was immediately dismissed. When asked whether they would like to go out in the evening, the person told staff they wanted to go to the pub. The staff member agreed at the time, but later told us, laughing, that they would not be going and they had only agreed in the moment. This response was disrespectful, demonstrated a power imbalance, and showed a disregard for the person’s wishes and autonomy. A review of records and discussions with staff confirmed that no one across the service was supported to go out in the evenings, meaning people were denied ordinary life choices and opportunities available to others in the community.

People were also not supported to develop independence in their daily living skills. Staff completed most household tasks without involving people, limiting opportunities for people to learn, participate and build confidence in managing aspects of their own home. Support plans did not include goals, strategies or approaches for developing independence, and there was no evidence that people were routinely supported to take an active role in cooking, cleaning, shopping, or other daily tasks. This lack of focus on independence restricted people’s ability to develop essential life skills and reduced their sense of ownership and control over their lives.

The cumulative impact of these failings was that people experienced institutional, provider‑led routines, limited choice, and reduced autonomy. People were not enabled to make everyday decisions, pursue meaningful opportunities, or lead rich, varied lives.

Following our assessment the provider told us they had made changes to the way support times were organised to give people greater flexibility and control.

The provider did not always listen to and understand people’s needs, views and wishes. Staff did not always respond to people’s needs in the moment or act to minimise any discomfort, concern or distress.

The way staff responded to people’s needs in the moment varied across the supported living settings and individuals' specific support needs. We observed staff offer reassurance and understanding to people when they became upset. They provided people with an explanation of what was happening, why and what they would do next. This helped to assure people they were being listened to, and their needs at that time were understood. In other instances, we observed that people’s distress was largely ignored or treated as a ‘behaviour’ rather than trying to establish and mitigate the cause. This led to people becoming increasingly anxious and unsettled on several occasions. Discussions with staff indicated they saw some people’s anxiety and distress as an inevitable part of their needs rather than something they aimed to support them to minimise.

The provider did not always care about and promote the wellbeing of their staff. They did not always support or enable staff to deliver person-centred care.

Staff told us they felt supported by the provider and were always able to access a member of the management team when needed. One staff member told us, “We can always call on them for advice or support. It makes it better to know they are there when needed.”

Despite these comments, we found some staff did not consistently receive the support they required to ensure their safety and well-being whilst at work. The provider employed an independent organisation to gather staff feedback on the service and support they received. This highlighted ongoing concerns about staff welfare, care delivery, and incident management.

Despite these concerns being expressed by staff, there was no clear plan to increase support provided to address these issues.

In addition, the lack of action in relation to the number and intensity of incidents meant staff in some settings were supporting people experiencing regular incidents of distressed behaviour with little effective support from the management team. This lack of oversight of incidents, training, and supervision increased risks to both people and staff.

Following the assessment the provider told us they had invested in an employee support programme to offer additional support to staff.