Amber Home Carers Surrey

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant services were not planned or delivered in ways that met people’s needs.

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

This service scored 32 (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 at the centre of their care, and they did not work in partnership with people to understand how they wanted to be supported. Care records did not contain information about how people wished to be involved in decisions regarding their support, how their needs should be reviewed, or how their preferences, aspirations and goals should shape their care. This demonstrated a fundamental lack of person‑centred practice.

Care plans lacked essential detail about how people’s support should be delivered in a way that respected their individuality. There was no information about which staff people preferred to support them, how staff were chosen, or how people were involved in selecting their team. This meant support arrangements were determined by organisational convenience rather than personal preference.

The service supported most people with at least one‑to‑one staffing, including during the night for several individuals. Despite this level of intensive support, there was no guidance outlining what one‑to‑one support should look like for each person. Because of this lack of clarity, staff adopted a blanket, non‑individualised approach. Staff told us they stayed with people at all times, and where one‑to‑one was provided overnight, they remained inside people’s bedrooms while they were sleeping. There was no evidence that this level of intrusion had been discussed with the person, assessed individually, or reviewed to consider the least restrictive option. This resulted in people receiving care that did not promote privacy, dignity or independence.

The lack of personalised guidance meant staff were making moment‑to‑moment decisions without understanding people’s preferences, boundaries or expectations. This removed people’s ability to have control over their care and denied them the right to make choices about how they were supported. The absence of person‑centred planning also meant people were not enabled to develop autonomy, influence their support, or express what mattered to them.

These failings were systemic, not isolated. Across the service, people experienced highly intrusive and standardised support arrangements that were not tailored to their needs or wishes. People were placed in a passive role, with decisions made about them rather than with them. This demonstrated a deep‑rooted lack of partnership working and a failure to uphold the principles of person‑centred care.

Following our assessment the provider sent evidence to show people’s support plans had been updated to included information regarding how people wished to be supported at night.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

Clear and accurate information was not available to share with other services, such as when people were admitted to the hospital. Records lacked detail regarding people’s health conditions and support needs, which would be essential information for services supporting them. Although this was mitigated to a degree as people would always be accompanied by staff, there was a risk that information would not be known or remembered by the staff members present.

Records of people’s daily support were difficult to interpret as they were not always completed in a timely way, with several staff members recording the same incident, discussion, or support needs at different times. This presented difficulties for the provider and other services when trying to investigate incidents and establish a chronology of events.

The provider did not supply appropriate, accurate or up‑to‑date information in formats tailored to people’s individual communication needs. Communication plans lacked essential, person‑centred detail and did not describe how people expressed themselves, how they used communication systems or what their signs, gestures or behaviours meant. This resulted in people being unable to understand information, express their needs or make informed choices about their care.

We found that people’s communication plans were not consistently followed. One person’s plan clearly stated that they should be supported using the Picture Exchange Communication System (PECS) and a pictorial activity board. Despite this, when the person became upset, staff relied solely on verbal reassurance, which had little effect, and did not use PECS or any visual aids as instructed. This meant the person was left without an effective means to understand what was happening or to communicate their needs, increasing their distress. This lack of adherence to their communication plan demonstrated a failure to provide person‑centred and accessible support.

Communication plans for two other people also recommended use of pictorial activity boards. However, only whiteboards with handwritten text were available. One person told us they could not read or understand the information and the second persons records also refcected they were unable to read. Staff acknowledged the boards were primarily for staff reference rather than for the people using the service. This revealed a fundamental lack of understanding among staff about the purpose and importance of communication aids in enabling people to express themselves, understand their routines and make decisions.

Because communication systems were not available, not maintained and not used, people were routinely denied their right to communicate effectively. They were unable to understand their daily activities, express preferences, or be involved in decision‑making about their support. This created significant risk of unmet needs, misunderstandings and avoidable distress.

The impact of these failings was substantial. People relied on communication systems that were either not provided, not understood by staff or not used in practice. Without accessible communication, people had limited ability to influence their care, understand what was happening, or have their choices respected.

The provider did not make it easy for people to share feedback, raise concerns or influence decisions about their care, treatment or support. People were not encouraged or empowered to express their views, and there was no evidence that staff meaningfully involved people or told them what had changed as a result of their feedback. This demonstrated a lack of partnership working and failed to uphold person‑centred principles.

The provider did not maintain a complaints log or follow appropriate processes when responding to concerns. During our assessment, the provider told us they had no central record of complaints and would need to search email accounts to retrieve information. The records they produced only covered the three months prior to the assessment. The provider stated that no earlier information existed because the previous manager had not logged any concerns. This meant there was no reliable record of complaints, no evidence of how concerns had been investigated, and no assurance that actions had been taken to resolve issues.

While the most recent complaints had been responded to, the provider had not carried out any thematic analysis or review to identify trends, risks or recurring issues. The absence of learning and oversight meant that concerns were likely to reoccur, leaving people and staff exposed to avoidable risk and poor‑quality care.

People were not routinely asked for their views on the service. There was no system to ensure feedback was collected consistently, including from those who found it difficult to express their views verbally. This significantly restricted people’s ability to influence improvements or highlight concerns about their care.

The provider told us they had begun inviting relatives to house meetings to discuss people’s support. However, the minutes of these meetings did not demonstrate how people themselves had been involved, what their views were, or how any actions would be taken forward. There was no evidence that people’s voices shaped the decisions being made about their daily lives.

The lack of a functioning feedback process meant people had no effective route to raise concerns, and the provider had no mechanism to identify learning, improve practice, or assure themselves of the quality and safety of care.

The provider did not ensure people could access the health care, treatment and support they needed when they needed it. Systems to plan, monitor and review people’s health appointments were ineffective, placing people at significant risk of not receiving essential treatment.

One relative told us that repeated failures in planning had resulted in their family member missing several health appointments needed to receive prescribed medicines. They said this had caused their family member unnecessary upset and difficulties,showing the direct and avoidable impact of these failings on people’s wellbeing.

Although some records showed that people attended health appointments, the absence of health action plans and detailed tracking meant it was not possible to establish whether appointments had been arranged when required, whether follow‑up advice had been provided, or whether this had been acted upon. This lack of oversight meant the provider could not be assured that people’s health needs were being met safely or consistently.

Information about the outcomes of appointments, discharge notes and referrals was not consistently recorded. This meant there was no reliable chronology of people’s health, no clear record of clinical advice, and no assurance that important information was shared with staff or acted upon. When we requested information regarding people’s recent health appointments, the provider was unable to locate this in the records and instead had to phone the staff on duty to ask what had happened. This reliance on anecdotal information and the memory of individual staff members was unsafe and created a significant risk of missed treatments, missed follow‑ups, and deterioration in people’s health.

The cumulative effect of these failings was that people did not have safe, coordinated or well‑managed access to healthcare. The lack of accurate, up‑to‑date health information meant the provider could not respond promptly to changing needs, ensure continuity of care or demonstrate that people’s health conditions were being monitored and reviewed.

Following our assessment the provider sent evidence that a health tracker had been implemented to monitor people’s health needs more closely.

Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this. People’s care records did not refer to their individual equality and diversity needs. Most people receiving support had a learning disability, autism, mental health support needs or were living with dementia. Despite people living with these known barriers to equality, there was no process in place to monitor whether people had opportunities and positive outcomes. This had led to some people living with others with whom they did not get along, a lack of flexibility for some people regarding how they spent their time and opportunities for education and work not being fully explored.

In other areas, we found the provider had implemented support to ensure people were able to access things they enjoyed, as transport had been made available for people who found accessing public transport difficult.

The provider did not ensure people were supported to plan for important life changes or make informed decisions about their future, including at the end of their life. This lack of planning placed people at significant risk of distress, instability and unsafe transitions.

Around the time of our assessment plans were being made for 3 people to move to new accommodation. We found the processes around their transitions were not robust or fully transparent. One person told us they were excited to move and had already visited their new home. However, the professionals funding their care had not been informed and only became aware of the planned move during an unannounced visit. When they assessed the situation, they determined the move was not in the person’s best interests and had to intervene to arrange safer, more appropriate support. This demonstrated a failure in communication, partnership working and safeguarding people’s rights.

We reviewed information for two other people preparing to move to different accommodation. There was no evidence of a transition plan to prepare them emotionally or practically for the change. No steps had been taken to help them understand the move, meet their new staff team, or visit their future home. As a result of the provider’s lack of preparation, both moves had to be delayed until plans could be put in place. This reactive approach exposed people to unnecessary uncertainty and distress and did not support a safe or well‑managed transition.

People’s care records contained no information about their end‑of‑life wishes. The provider told us this was not something they discussed with people, and they had not sought professional guidance on how to approach these conversations sensitively or appropriately. This meant people had no opportunity to express their preferences, cultural needs, spiritual wishes or decisions about future care, and the provider had no understanding of how to ensure people could experience a dignified and personalised end‑of‑life journey.

The lack of any structured planning for major life events, including moves and end‑of‑life care, meant people were left without the support they needed to prepare for significant changes, and decisions were made about them without proper consultation, assessment or oversight.