Amber Home Carers Surrey

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to 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 have a shared vision, strategy or culture based on transparency, equity, equality, human rights, diversity, inclusion or meaningful engagement. Leaders did not understand the challenges people faced or the needs of the local community, and this lack of insight contributed to systemic failures in the quality and safety of care.

There was evidence of a closed culture within the service, which significantly increased the risk of harm, abuse and breaches of people’s human rights. The provider and management team did not share important information about people’s wellbeing or safety with external professionals in an open and transparent way. As a result, safeguarding bodies and commissioning authorities were unaware of repeated incidents and known risks, leaving them unable to offer timely oversight, intervention or support. This failure to share information prevented external scrutiny and placed both people and staff at continued risk.

Although leaders and staff spoke about wanting people to have a “good life,” they did not implement coherent or person‑centred strategies to achieve this. Concerns and poor practices in how people were supported had not been identified, addressed or monitored. The provider did not recognise that people’s support lacked structure, direction or alignment with their needs, preferences or aspirations.

This lack of leadership oversight meant that significant concerns went unnoticed and unchallenged, and people continued to receive care that did not enhance their lives or uphold their rights. The absence of an inclusive leadership culture, combined with poor transparency and inadequate governance, demonstrated a widespread failure to provide safe, well‑led, person‑centred care.

The provider did not have inclusive or capable leaders who understood the context in which they delivered care or who modelled the values expected within a service supporting people with complex needs. Leaders lacked the skills, knowledge and experience required to run the service safely and did not demonstrate integrity, openness or accountability in their approach.

There was a significant lack of leadership capacity and role clarity within the management team. The registered manager, who was also the Nominated Individual, had been absent for several months. During this period, several different managers were placed in the role, most of whom had limited or no experience of leading services for people with a learning disability or autistic people. Despite this, the provider did not implement any additional oversight, supervision or structured support to help them develop the competence they needed. This left the service without stable, informed leadership during a period when risks were escalating.

Leaders did not understand the importance of being visible in the service. There was minimal evidence that members of the management team spent time in people’s homes, observed staff practice, or engaged directly with people who used the service. This lack of engagement meant leaders did not recognise serious shortfalls in the quality of support or take action to address them. Their absence and limited insight directly contributed to people not receiving the care, consistency or support they needed and deserved.

The cumulative effect of these failings demonstrated a systemic leadership breakdown. Leaders did not ensure a safe, person‑centred or rights‑based culture. They were unaware of risks, disconnected from practice, and unable to provide staff with the guidance and oversight required. As a result, people were placed at avoidable risk of poor care and negative experiences.

Following the assessment the provider informed us they were in the process of restructuring the management team and training within the service. They told us they believed these changes would bring greater oversight and support to people and staff.

People and their relatives did not always feel they could speak up and that their voice would be heard. We received mixed responses regarding how the service responded to requests for information or feedback on the service. One relative told us, “It is extremely difficult to get a straight response to any queries. They don’t seem to listen; say they will get back and then don’t or you speak to someone different and get another story.” Another relative felt the management team were more responsive. They told us, “The management respond well to requests but may time to implement them.”

The provider had failed to implement systems to support people in expressing their views. People were not asked for their opinions on how they were supported, who they preferred to be supported by or who they wished to live with. No individual communication systems for assessing people’s satisfaction or observational assessments of people’s support were undertaken. This led to people having limited influence over their day to day lives and the care and support they received.

The provider did not always value diversity in their workforce. They did not always strive towards an inclusive and fair culture by promoting equality and equity for their employees. Staff told us they felt they were treated equally and that the management listened to requests for personal support. One staff member told us, “They are very good to work for and are interested in the welfare of the staff. They have helped me, and I have learnt a lot.”

Despite the positive feedback from staff, we found the provider had not implemented effective systems to provide staff with additional support, despite identifying this as a need. The provider informed us that they had identified gaps in staff knowledge when supporting individuals due to their cultural experiences with care services. However, they had not implemented effective training or mentoring to support staff with these specific needs, putting both staff and the people they were supporting at risk of harm.

The provider did not have clear responsibilities, roles or systems of accountability, and governance arrangements were ineffective. Leaders did not act on information relating to risk, performance or outcomes, and they did not share essential information securely or in line with regulatory requirements. As a result, the provider had no reliable oversight of the safety, quality or effectiveness of the service.

There was no consistent audit system in place. The provider had not implemented any processes to record, monitor or follow up on concerns. This meant the provider had no mechanism to identify unsafe practice, assess people’s experiences, or ensure staff had the skills and support required. Significant risks to the safety and wellbeing of both people and staff went undetected, unchallenged and unmitigated.

The provider had also failed to comply with their regulatory responsibilities. Registered providers must inform CQC of specific incidents so that we can monitor risk and protect people. However, the provider had not notified CQC of a high number of safeguarding concerns, incidents of police involvement, injuries sustained by people or the prolonged absence of the registered manager / Nominated Individual

These were significant events that should have been reported immediately. The provider’s failure to do so prevented CQC from having oversight of escalating risks and meant serious concerns were not scrutinised, investigated or addressed in a timely way.

The lack of governance, transparency and regulatory compliance placed people at ongoing risk of harm. Without reliable systems to monitor quality, leaders were unable to identify poor practice, respond to concerns, or drive improvement.

Following the inspection we received assurances from the provider that new monitoring and auditing systems had been introduced and that managers were visiting people’s homes more regularly.

The provider did not understand their duty to collaborate and work in partnership with other organisations to ensure services worked safely and effectively for people. They did not share essential information or learning with partner agencies and did not collaborate to support improvement or manage risks.

During our assessment, we received mixed feedback from partner organisations about how well the provider worked with them. Although some partners described the service as flexible, several agencies reported significant concerns about the provider’s failure to respond to requests for information and their reluctance to work openly and transparently. This included not sharing important information about the level of people’s distressed behaviours, arranging moves to new accommodation without consultation, and failing to be open when incidents occurred. These omissions prevented partner agencies from understanding risks, planning safe support, and fulfilling their safeguarding responsibilities.

Some agencies told us they were unaware of key details such as the nature of people’s tenancy agreements, and that information remained unclear even after repeated requests. Several partners reported that the lack of transparency had led to a loss of trust in the provider, and in their ability to deliver safe, effective and well‑coordinated support.

This breakdown in partnership working placed people at significant risk. Without open communication and shared understanding of people’s needs, risks were not appropriately monitored or mitigated, and opportunities for safe, planned and integrated care were missed. The provider’s failure to collaborate or share information safely demonstrated a systemic leadership failure that significantly compromised people’s care and outcomes.

The provider did not demonstrate a culture of continuous learning, improvement or innovation across the organisation. They did not promote creative or person‑centred approaches to improving people’s quality of life, nor did they contribute to safe or effective practice within the local system. This reflected a fundamental failure of leadership and governance.

The provider returned to full‑time work only after being made aware of significant shortfalls identified by the local authority’s quality assurance team. Although some initial steps were taken to review the management structure, the provider had not undertaken a comprehensive assessment of people’s needs, the quality of their support or the systems and processes underpinning the service. As a result, they lacked a clear, accurate and holistic understanding of the extent of the concerns and the improvements required.

There was no structured or credible improvement plan in place. The provider had not identified who would take responsibility for actions, how improvements would be monitored, what success would look like, or the timescales for completion. Without these essential governance elements, there was no assurance that improvements would be delivered, sustained or evaluated.

Following our first site visit, we requested an urgent action plan detailing how the provider would address the risks we had identified. While some immediate actions were taken, such as increasing management presence and reviewing medicines safety, the action plan submitted lacked detail, urgency and understanding of the seriousness of the concerns. It did not reflect meaningful learning, did not incorporate feedback from partner agencies or staff, and did not demonstrate how changes would be embedded in daily practice.

This demonstrated a systemic failure to recognise, understand or respond to risk, and an inability to implement effective learning and improvement. The absence of reflective practice, structured governance and proactive leadership placed people at ongoing risk of poor outcomes, unsafe care and unmet needs.

Following our assessment the provider informed us they were taking immediate action to learn from the shortfalls identified within the report. They described the systems implemented to monitor the progress being made and the investments made in staff training, electronic monitoring and auditing processes.