Amberley Care Home

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 requires improvement. 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 3 legal regulations. These were in relation to, safe care and treatment due to inadequate risk management and care planning. Safeguarding due to procedures not being followed to safeguard people from risk of harm and staffing due to unsafe recruitment practices.

This service scored 28 (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 proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The culture within the home was not always focused on safety and learning from incidents which had occurred. For example, records of incidents were not always analysed consistently for patterns and trends to mitigate future risks to people. Where analysis of incidents had been completed the information was inaccurate with the number of incidents which had occurred for that month. These records also lacked detail of how future risks would be reduced. There was a lack of evidence to demonstrate outcomes of any learning had been shared with staff. A lack of clear and consistent guidance for staff in relation to people's individual needs and risks meant a proactive culture of safety was not always demonstrated. This meant opportunities for learning and improvements in people’s care were not always implemented and embedded.

Relatives told us staff did keep them informed about incidents which may have occurred. A relative told us, “The staff do call me when [person] is not feeling well or if there has an incident, they are good like that.” However, due to the lack of consistent records we could not be assured relatives or representatives had been informed about all the incidents involving their family member/ person.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

Although systems were in place to assess people’s needs prior to their admission, we found these were not always used. For example, we reviewed the records for one person who had recently moved into the home for a short stay. We found the provider had not completed their own assessment of this person’s needs and had used the information shared by the hospital and Local Authority’s assessment. Following the person’s admission the provider did not complete a care plan or any risk assessments for this person. Staff relied upon the information shared by partner agencies to meet the person’s needs. This meant staff did not have access to an up-to-date care plan or any risk assessments which reflected the person’s current needs following their hospital admission. Action was taken when we brought this to the providers attention and a care plan was completed. However, the care plan did not include detailed information about the person’s medical needs following their hospital admission to ensure staff could consistently meet their needs and preferences.

We sought feedback from partner agencies who told us the provider was not always ‘proactive’ in implementing recommendations they had made to improve the systems in the home to monitor people’s safety and improve the records in place to support people’s continuity of care.

Some relatives we spoke to, told us they had been asked to provide some information as part of the admission process. A relative told us, “When [person] moved in, I was asked a few questions about what support [person] needed. I know [person] has a care plan, but I have not asked to see it.”

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

The provider had failed to ensure they consistently followed safeguarding procedures or responded appropriately to potential abuse. They had failed to protect people from potential harm and report concerns. For example, we found where people had fallen the circumstances leading to the fall had not always been explored to safeguard people from harm. Where people had repeated falls within a short timeframe or had sustained a serious injury this information had not been shared with the Local Authority as a safeguarding alert as required by their ‘Preventing falls’ procedures. Where needed, this then may have also resulted in a notification to be submitted to CQC that were not submitted.

We also found there had been potential safeguarding incidents in the home which had not been shared with Local Authority or CQC. Therefore, the provider had failed to follow their own internal procedures and that of partner agencies to safeguard people to prevent potential avoidable harm and neglect.

We saw from the training records not all staff had completed safeguarding training to ensure they had the skills and knowledge to safeguard people from abuse and neglect. However, staff we spoke with were able to tell us what action they would take if they had any concerns about people’s care. One staff member told us, “If I had any concerns I would report them to the manager.” People and their relatives told us they felt safe with the staff supporting them. One person said, “I feel safe with the staff they are a decent bunch.” A relative told us, “I have no concerns about [person’s]’ safety I think they are safe, and staff treat them well.”

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act (MCA). In care homes, this is usually through MCA application procedures called DoLS. Applications had been completed as required and systems were in place to maintain oversight of all authorisations in place to ensure they were lawful and in people’s best interests.

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.

The provider failed to manage risks effectively to ensure people received safe care. The management of risk was of concern during our previous inspections and sufficient improvements have not been made. We found multiple aspects of the service were unsafe which placed people’s health and safety at risk. For example, we found multiple people had fallen but it was unclear from the records and discussions with staff what actions had been taken to reduce the risks of future falls. In addition, some people’s care plans and risk assessments had not been updated in response to these falls to provide guidance to staff on how they should support people to reduce future falls risks.

The provider has failed to take action to ensure water used by people in their bedrooms and in communal areas was maintained at safe levels to prevent the risk of scalding. Records provided to us of checks on water temperatures showed areas in the home where the hot water had exceeded the recommended safe level of 44c. No action had been taken in relation to these recordings until we raised this with the provider on our inspection. The provider then took immediate action to address these risks.

During the inspection we observed staff use unsafe moving and handling techniques when supporting people to transfer to and from chairs. Staff placed their hands under peoples’ armpits to support them to transfer. We observed these practices on 3 occasions during our inspection. These practices placed both people and staff at risk of harm.

Where people had known health conditions which placed them at risk of harm, staff were not always provided with clear information and guidance on supporting people in relation to these and managing associated risks. For example, where people had diabetes, epilepsy, or heart conditions.

We received mixed feedback from people and their relatives about the management of risks. Some people and relatives told us staff supported them to well to manage risks when mobilising. Whereas other relatives told us they had raised concerns with staff for example, about the risks of people developing sore skin.

We found in discussions with staff they knew people’s needs and told us they understood how to manage people’s care in a safe way. People were supported by a consistent staff team.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The provider failed to identify and take steps to control potential risks within the home in a timely way. During a tour of the environment, we identified several risks to people. For example, inappropriate window restrictors in some people’s bedrooms. These did not meet current recommended guidelines. We found the laundry room was accessible to people as it was unlocked. The window within this room did not have a restrictor fitted. We found exposed pipework located near to people’s bedrooms which was very hot to touch. We saw an unlocked bedroom which was used as a storeroom and contained many hazardous items, such as tools. The provider took immediate action when we brought these risks to their attention.

We observed many doors being propped open by wedges or commodes and chairs. This is a fire safety risk and placed people at risk of harm. However, the registered manager and staff advised us these were all removed on an evening. The provider told us these risks would be removed as a new fire system was being installed throughout the home including devices being fitted to all doors so they could remain open but would close in the event of a fire. We observed this work commenced on day 2 on our inspection.

People and relatives, we spoke with did not raise any concerns in relation to the environment being unsafe.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The provider failed to ensure all staff received appropriate training to meet the needs of people and their known health conditions. This included mental and physical health conditions with a long-term impact on people’s care, such as heart failure, and complex dementia. Records demonstrated some staff had not received core training for their role, for example, practical moving and handling training, and safeguarding. This meant staff may not have had the knowledge or skills to support people safely. The provider failed to carry out spot checks or competency assessments to observe staff practices in areas such as moving and handling and supporting people with complex dementia. This meant the provider could not be assured staff were safely and effectively meeting people’s needs. Our observations of staff performance confirmed staff did not always have the skills to support people safely in these areas. The registered manager and team leader did take action following our feedback to arrange and planned various face to face training for staff in the forthcoming weeks.

We received mixed feedback from people and relatives about the staffing levels within the home. One person said, “Yes the staff are always around and come when I press my buzzer.” However, a relative told us, “The staff are always so busy I think they are understaffed.” We observed times during peak times of activity such as morning and breakfast where staff were not always available to support people. For example, we saw one person struggling to place food on their spoon at breakfast and staff were not available to support. We observed 2 people had a heated interaction with each other and staff were not available to intervene. At times when 3 staff were on duty we observed 2 staff outside having a comfort break together. The provider did not have a policy in place for this or a dependency tool to demonstrate how they monitored and maintained oversight of the staffing levels in accordance with people’s dependency needs.

The provider's recruitment systems were not effective. Safe recruitment practices were not always followed. People were at risk of harm from receiving care and support from unsuitable staff. We reviewed the recruitment files for 3 staff which had recently been recruited. The provider had failed to evidence they had explored any gaps in employment records for 2 staffmembersand mitigate any associated risks. Where a staff member had a reference which raised concerns about their performance, this had not been explored or risk assessed. Where staff had previously had a care related role a reference from the employer had not been sought for 2 staff or a rationale provided for this. This meant due to the lack of records we could not review the rationales for these decisions and the safeguards put in place to ensure the staff members were suitable to work with vulnerable people.

People and relatives, we spoke with did not raise any concerns about staff not having the required skills for their role.

Staff told us they felt supported in their role. Staff told us and the records confirmed supervisions were provided although they were not consistent. A staff member said, “I do feel supported in my role, and I don’t wait for formal supervision to ask questions. The registered manager is always there if I have a question or need any advice.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We found several areas of the home required improvements due to being worn. For example, some commode chairs were ripped, a sensor mat which was being used had been taped up due to wear and tear. Some bedrooms needed redecorating due to flaking or damaged paintwork. We observed damaged walls, and damaged cupboards in communal areas. The provider took immediate action to address some of these issues when we raised them. For example, commode chairs were replaced. The provider told us they intended to complete a refurbishment of the home, and we requested an action plan. However, this has not been provided to us. The home appeared clean during our inspection.

People and relatives told us they thought the environment could be improved. A person said, “I would like my room painted it’s a bit old and tired now.” A relative said. “The home is a bit dated and could do with some decoration in some areas. The bedding is also a bit shabby.”

Staff told us and we saw they had sufficient personal protective clothing to use to prevent infections and contamination. Cleaning schedules were completed but these did not include the cleaning of equipment which was used or pressure cushions to ensure people were safe from cross infection.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

People did not always received there medicines as prescribed. Although people told us and most records showed people received their medicines as prescribed, we found improvements were needed with the way medicines were managed. For example, we found the records for medicines which were being stored and recorded as controlled drugs were inaccurate. The controlled drugs record stated medicines had been returned as they had expired. However, we found these medicines were still in the home. Some people received medicines to support with their anxiety to be given as required. Records were not in place to demonstrate what alternative actions had been tried such as de-escalation techniques before these medicines had been administered. This meant we could not be assured these medicines had been given in peoples best interests.

Some people were prescribed eye drops to be given daily. For some people, there were gaps in their medicines record with no rationale recorded. This meant we could not be assured people had received their eye drops as prescribed to treat their eye condition placing them at risk of harm.

We found medicine records for prescribed creams were not always signed to confirm people had these applied as prescribed. Where people were prescribed medicines which needed to be administered at specific times the records did not always reflect the actual time people had received these.

We found some people administered their own medicines, however a risk assessment had not been completed to demonstrate they were safe and competent to do this and if they required any support. We found one person was using an out-of-date prescribed cream by a year. No action had been taken to replace this cream. When we raised this with the management team, they told us they were not aware of this cream was still being used.

Some people were prescribed nutritional supplements however, the stock balance for these was inaccurate. Therefore, we could not be assured people had received these as prescribed to support their diet. We also found some of the guidance for administering ‘as required’ medicines lacked detail to guide staff about the signs and symptoms they needed to be aware of. This placed people at an increased risk of receiving their medicines unsafely.