Amber Home Carers Surrey

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation, in relation to people’s safe care and treatment, the ways people’s medicines were managed safely, how people were safeguarded from the risk of abuse, and how staff were trained and supported within their roles.

This service scored 31 (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 promote a proactive or positive safety culture based on openness and honesty. Concerns about safety were not listened to, and safety incidents were not consistently investigated or reported. There was limited evidence that learning from incidents took place, meaning the provider did not identify or embed improvements in practice.

Relatives provided mixed responses to how the service responded to accidents and incidents. One relative told us, “The staff team need more structure. They need seniors in the house to give direction. They don’t analyse the data (from incidents and concerns) for any trends.” Another relative told us the approach of staff had reduced incidents of the family member being distressed.

We found the provider did not have a systematic approach to the review and reporting of accidents and incidents. Incidents were recorded in a number of different ways including within daily records, on monitoring charts and on accident and incident forms. As the management team were not reviewing this range of records, they were not fully aware of how incidents were impacting people’s lives. Records showed a high level of incidents including physical and verbal altercations between people, people experiencing high emotional and distressed behaviours, incidents involving the police, medicines errors and health concerns. The provider was able to demonstrate action had been taken in relation to some individual concerns. However, the lack of a systematic approach meant themes and trends had not been identified and learning had not been shared across the service. Where accident and incident forms were completed, there was limited follow-up from the management team to show the incident had been investigated, what conclusions had been reached and what action had been taken to keep people safe going forward.

The provider did not work effectively with people or with health and social care partners to establish and maintain safe systems of care. They did not monitor or manage people’s safety in a coordinated way, and there was no assurance that people experienced continuity of care, including when moving between services.

Partner agencies told us communication from the provider could be poor. They reported they were not consistently informed about people’s needs, changes in risk, or future plans. This lack of communication meant emerging concerns were not identified or addressed, placing people at risk of harm.

During our assessment, we were informed that several people were due to move to alternative accommodation the provider believed would better meet their needs. However, partner organisations and local authorities funding people’s care had not been properly informed of these proposed moves. This meant people were at significant risk of not having the correct support, equipment or planning in place to ensure a safe transition. It also meant partner organisations could not be assured that decisions were being made in people’s best interests.

In some areas we found the provider worked positively with professionals. Training in specific areas of people’s needs had been provided by external professionals and attended by staff. This included training in different communication styles and in relation to one person’s health needs.

The provider did not work effectively with people or with health and social care partners to understand what being safe meant for each person or to plan how to achieve it. Concerns about safety were not shared promptly or appropriately. The management team and staff observed or were informed of repeated incidents of verbal and physical aggression between people but did not recognise these as safeguarding concerns. These incidents were not reported to the local authority safeguarding team or notified to the Care Quality Commission in line with statutory requirements. This prevented external oversight and delayed actions to protect people from harm and abuse.

There were no systems in place to monitor or oversee known risks for people who harmed themselves when distressed. The service did not maintain an incident log that linked episodes to injuries sustained, so patterns and triggers were not identified. In addition, care records contained references to restraint being used with one person during distress; however, the person had not been assessed as requiring this level of intervention, there was no guidance in place, and no review or investigation of these reports had been completed. This lack of assessment, planning and oversight placed people at significant risk of avoidable harm.

We discussed our concerns with the provider regarding the lack of safeguarding reporting and the high number of incidents affecting some people being supported. The registered manager told us they were aware that staff in some settings had become desensitised to the frequency of incidents and were failing to escalate concerns. There was no evidence that robust action had been taken to address this or to ensure a regular management presence to oversee people’s safety.

In one setting, we observed several incidents that met the threshold for referral to the local authority safeguarding team. However, staff records did not demonstrate an understanding that the ongoing friction, and regular verbal and physical altercations between people, constituted safeguarding concerns. These incidents were not recognised as unacceptable or as situations that required external reporting.

During our assessment, we asked the registered manager to review the relevant records and ensure safeguarding concerns were retrospectively shared with the local authority. Despite this request, the information was not forwarded, and safeguarding alerts were not raised. We therefore notified the local authorities ourselves to ensure the concerns were reviewed and investigated appropriately.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

People were placed at significant risk of harm due to ineffective management of emotional distressed behaviour, , and past trauma. Care plans, risk management plans and positive behaviour support plans (PBS) did not consistently identify triggers to people’s distress and anxiety or provide clear guidance for staff to follow. This meant staff did not have information on how they should support people to manage risks to their safety and that of others around them. PBS plans had been written by an external company that had not met people and had not observed staff providing their care. This meant they had not conducted a comprehensive assessment of people’s needs prior to developing their PBS plans. Where guidance was provided within PBS plans, we observed that this was not always followed by staff. There were no recorded checks to demonstrate that staff were following the guidance provided. The failure to understand, plan for, and respond to people’s behaviours, anxiety, and trauma placed them at ongoing risk of distress, injury, and deterioration of their emotional wellbeing.

Risks related to people’s healthcare needs were not specifically assessed. This meant that staff did not have the information they required to identify health concerns and understand what action should be taken to support people effectively and safely.

Risk assessment processes were not consistent, and assessments relating to specific areas of support were not in place. This included plans for attending health appointment, visiting new places or managing anxiety when in public. This demonstrated a lack of understanding regarding people’s specific needs, how they managed new environments and how staff needed to support people in planning different opportunities.

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.

The provider told us checks of all properties were completed regularly. Records showed that in May and June 2025 these were recorded electronically and gave a description of what had been checked and any issues identified. Since this date, there were records to show periodic checks were completed although there was no detail of what was looked for or what action was required. Checks completed in one property in June 2025 highlighted significant issues with the environment, including extensive damp. Whilst the provider was trying to address these issues and looking for people to move to a different property, there was no detailed plan regarding how people would be supported with these concerns in the meantime. In addition, we found wires had been cello taped to the wall in the hallway of one setting rather than safely installed. There was no maintenance record of this being reported.

In other areas, we observed people were supported to maintain their property to a good standard. Staff told us that should they identify any concerns these were reported to the office and would be rectified in a reasonable time. Safety checks of equipment were completed by external professionals as required such as checks on gas safety and electrical items.

The provider did not ensure staff had the skills, knowledge or experience required to support people safely. Staff did not always receive effective training, supervision or development, and they did not work together consistently to provide safe care that met people’s individual needs.

Relatives gave mixed feedback about staff skills. One relative told us, “The carers are a good team. They do on-the-job training, especially around behaviours.” Another relative said, “The staff are nice, but they just don’t have the skills or the understanding they need. I really worry (family member) isn’t safe.”

Staff had not received the training they required to support people safely. Although mandatory training had been completed in areas such as medicines and moving and handling, there were no competency assessments to confirm staff understood how to apply this safely in practice. The provider told us bespoke PBS training was being delivered, but the person delivering this training had not met people or observed their support. Significant gaps in people’s PBS plans meant this training did not provide staff with the information they needed to support people safely.

Staff did not receive consistent supervision or support in their roles. Of the 109 staff listed in training records, only 8 had supervision recorded. These took place in June 2025, with no evidence of any supervision before or after this date. The registered manager told us spot checks were completed to monitor staff performance; however, records showed these occurred only in May and June 2025 and focused on task‑based observations rather than people’s support or staff development needs.

Staff were not always recruited safely. Although references and recruitment checks were obtained, records showed these were frequently completed after staff had started work. There was no evidence that the risks associated with this practice had been assessed or mitigated. This placed people at significant risk of harm.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

People were not always supported to maintain a good level of hygiene within their homes. We found areas such as hallways and bathrooms in some people’s homes were unclean, despite people needing support with these tasks. In one person’s home we observed a staff member leave the bathroom wearing protective gloves after supporting a person with their personal care needs. They continued to wear the gloves as they supported the person, holding their hand and moving around their home. This presented a risk of spreading infection as well as being undignified for the person.

Staff completed infection control training and confirmed they always had access to personal protective equipment such as gloves and aprons.

The provider did not ensure medicines were managed safely or in a way that met people’s needs, capacities or preferences. People were not involved in planning their medicines support, and we received several concerns from relatives about how medicines were handled.

Safe medicines processes were not followed, placing people at significant risk of harm. There were no effective systems to order or monitor medicines. We found one person’s rescue medicines were out of date, and another person had experienced a serious health incident because their prescribed medicine was not in stock. A further person’s emergency medicine for a specific health condition was not available. Staff were not aware the medicine had been prescribed and did not understand when or how it should be used.

Medicines were not dispensed safely, and accurate records were not maintained. The provider used both paper and electronic systems, and we found multiple discrepancies between them. This meant the provider could not be assured that people had received their medicines as prescribed. In addition, staff were re‑packaging one person’s medicines into an unlabelled weekly medicines box for use throughout the week. This is known as secondary dispensing and is not considered safe practice by the Royal Pharmaceutical Society as it increases the risk of errors.

Staff had not received the training or assessment they needed to support people safely with their medicines. Guidance was not routinely available for people prescribed ‘as required’ (PRN) medicines, so staff did not know what, when or how these should be offered. Although staff had completed online medicines training, no competency assessments had been undertaken to confirm they had the necessary knowledge and skills to support people safely.