Amberley Care Home

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 inadequate. At this assessment the rating has remained 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 1 legal regulation in relation to inadequate governance at the service.

This service scored 36 (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 and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider had not developed a clear vision, strategy or set of values, aims and aspirations for the service which staff knew about and followed. Staff when asked, did not know what the vision of the service was. When asked, the provider told us the vision was to deliver ‘quality care and quality of life’.

The providers leadership did not demonstrate how they supported the management team to place people at the heart of the service, protect them from harm and enable them to live their best life. The culture of the home was not based on the promotion of learning and improvement. There was a lack of consistent staff meetings, supervisions and observations of staff practices to ensure staff received the support and feedback about their performance to help drive improvements in the home.

Reviews of people’s care plans had not ensured a fully inclusive and collaborative process of care plan development. The provider had not ensured staff had completed core, or specific training in accordance with people’s individual needs to promote equality, diversity, inclusion and engagement.

Staff told us they, ‘tried their best in challenging circumstances’ and aimed to provide ‘good care’ The staff had some understanding of what a closed culture was and told us they would report any concerns about poor practices.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

The provider visited daily; however, they failed to have the skills, knowledge and experience to provide support and guidance to the staff team. The provider failed to maintain oversight of the quality of care being provided therefore sufficient improvements had not been made since our previous inspection. The provider failed to demonstrate they led by example with promoting inclusive behaviours. The provider and management team had not always acted with honesty and integrity as they had not shared information of concern with partner agencies. There was a lack of evidence to support discussions held with people’s relatives about incidents to demonstrate if the requirements of the duty of candour had been fully met.

The provider was receptive to our feedback and took some steps to immediately improve safety in the home following our feedback.

People did not always feel they could speak up and that their voice would be heard.

The provider had failed to adopt an inclusive approach in gathering regular feedback from people, relatives and staff to give them the opportunity to share any concerns they may have.

Relatives could not tell us the last time they were asked for feedback about the care provider. But they did feel confident to speak up if there were any issues. We saw some efforts had been made and individual feedback had recently been obtained from people who were asked about their care.

We were told by the management team the last feedback surveys were sent out to people, relatives and staff was last year, however the results of these were not shared with us although we asked for this information.

Staff told us they did feel able to speak up to the registered manager who they described as ‘approachable’. Not all staff felt confident to speak with members of the provider team and some staff did not always feel valued by them. Staff were not involved or engaged in an improvement plan and were not aware of their role within any improvement processes following our previous inspection, and in response to the ongoing action plan with the Local Authority. Staff told us, “I know improvements need to be made as the rating is displayed but I am not sure in what areas.”

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There was a lack of oversight and monitoring of training completed by staff or consideration of any adjustments that may have been needed to how training was delivered to reflect staffs’ diverse needs. Most of the training provided was online training and the expectation was for staff to complete this at home in their own time. Therefore, the take up of training had previously been low. However there had been some recent changes in this area and more face-to-face training was planned and staff were beginning to be paid to complete training.

Most of the staff team had completed equality and diversity training. However, there was limited evidence to support if staff knowledge and skills had been assessed following learning, to check their understanding and how this had been applied in the service.

The registered manager told us they embraced and valued diversity in the workplace and confirmed reasonable adjustments had been made to accommodate staffs protected characteristics such as, time allocated for religious observance and flexible working for staff with ill-health.

Staff we spoke with told us their protected characteristics were respected by management team and their fellow peers. One staff member said, “I feel like I am treated equally and staff respect me.” Another staff member told us, “The manager is very good and listens to our individual circumstances and needs, I feel supported in that way.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider did not have effective systems or processes in place for the monitoring of the quality of care. Since our last inspection the provider had failed to have an overall development plan, to plan for, drive and sustain improvement to meet the previous breaches of regulations. Action plans had been sent to us which had been signed off by the provider. However, we found the information was not always accurate and did not reflect the risk within the home and lack of actions being taken to address these. For example, we found inaccurate and unclear information in people's care plans and risk management plans; poor management of risks; poor oversight of medicines, poor oversight of potential risks in the care environment; inconsistent support and recording in relation to people’s fluid intake, and a lack of analysis of incidents and accidents. The provider's auditing and monitoring of people's care was ineffective and placed people at risk of harm.

The provider failed to carry out audits of staff recruitment files to ensure all checks had been completed and safe processes had been followed. The provider failed to monitor staff had completed training to ensure they were competent in their roles. The provider had failed to ensure their safeguarding processes identified when people were at risk of abuse were robust. Where safeguarding concerns had been identified, procedures had not been followed to share this information with partners. We found the provider had failed to follow their own policies. This meant they were not always meeting the requirements of current legislation.

The provider failed to ensure medicines were managed safely and action taken to return unused medicines in a timely manner. For example, we found 7 tins of prescribed ‘Thickenup’ which is a food thickener used by people with swallowing difficulties. Some of these were for people who had not lived in the home for up to 3 months. We found first aid boxes contained several out-of-date items some of which had expired in 2011. This meant in the event of an emergency such items could not be used as they may be ineffective.

Systems were not in place to monitor the standard of daily notes completed by staff. The records did not clearly show what support people received, and the frequency people were checked when residing in their bedroom both during the day and night. Therefore, there was missed opportunities in identifying potential safeguarding incidents.

The provider had failed to meet the requirements of the regulations by failing to submit notifications to CQC in relation to reportable incidents and safeguarding referrals that had been shared with the Local Authority.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The management team engaged well with the local authority quality improvement team; however, our inspection showed they had not always shared key information with them and completed referrals of incidents. During the inspection information requested had not always been forthcoming. The provider did respond to requests to address serious concerns identified during our inspection.

People and relatives confirmed referrals had been made to health and social care professionals to gain support about people’s needs.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

This inspection showed there was no proactive development of the service since our last inspection. At this inspection, and over the course of our previous inspections, we have identified significant concerns in the safety and quality of people’s care, several of which represent repeated failings and breaches of regulations.

There was no plan about how the service kept up to date with developments in adult social care or dementia care to ensure care provided was appropriate and in accordance with best practice. Learning gaps and further development for staff were not identified, and opportunities were not offered to staff to progress and grow in their roles to improve people’s experiences.

There was no evidence to demonstrate the service engaged in local and national forums or development groups which would assist in gathering best practice knowledge to support improvement in the service, for example dementia care. There were no processes in place to review any lessons learned or any changes in practice to see if they worked well or not. The provider had failed to meet their legal requirements and demonstrate a commitment to drive the improvements in people’s care.