CQC report explained · a residential care home
What the CQC found at Amber House - Coventry
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- The home was not consistently clean, PPE was not always used correctly and uncovered hot water pipes created a burn risk. Inspectors also found enough staff, safe recruitment, safeguarding training and generally safe medicines arrangements.
- Effective?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward to calculate the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused inspection. Its previous rating was carried forward to calculate the overall rating.
- Well-led?
- Requires improvement
- Management checks did not identify poor cleanliness, uncovered hot water pipes or an overheated bedroom. The manager had also not always notified CQC about safeguarding events.
What inspectors found, April 2022
Rated Requires Improvement; inspectors found serious cleanliness and environmental safety problems, although immediate action reduced the risks.
Inspectors visited on 20 January and 8 February 2022. They first looked at infection prevention and control, then widened the inspection to Safe and Well-led after finding concerns about cleanliness and environmental risks.
On the first day, areas of the home were unclean, staff did not always wear PPE correctly and hot water pipes were uncovered. The home was also not monitoring these risks well enough. The provider took immediate action, including deep cleaning, covering the pipes, replacing flooring and giving staff refresher PPE training. Inspectors found the home clean and the pipes covered on the second day.
People and relatives said they felt safe and were happy with the care. Inspectors found enough staff, safe recruitment, suitable safeguarding training and generally safe medicines arrangements. However, the home was rated Requires Improvement overall, with Safe and Well-led both rated Requires Improvement. This means inspectors found important improvements were needed and there was limited assurance about safety.
Enough staff
Inspectors found there were enough staff to meet people's needs, including when people needed one-to-one or two-to-one support.
“There were enough staff to support people safely.” from the report
Safe medicines
Medicines were administered by trained staff and were received, stored and disposed of safely. Some as-needed medicine protocols were improved during the inspection.
“Medicines were managed safely and people received their medicines as prescribed.” from the report
Kind and settled care
People appeared comfortable with staff. People, relatives and staff described the home as calm, friendly and welcoming.
“The home had a calm and relaxed atmosphere. The culture at the home was warm and friendly.” from the report
Risk assessments
People's risks were identified, assessed and reviewed. Staff knew the steps needed to reduce those risks.
“People's risk assessments were regularly reviewed and updated.” from the report
Poor cleanliness
seriousInspectors found dirt and dust in communal areas, bathrooms, toilets, bedrooms and the visiting pod. Damaged flooring and paint also made effective cleaning harder.
“Numerous areas in the home had significant dirt and dust build up which showed regular, thorough cleaning had not been completed.” from the report
Burn risk from pipes
seriousSome radiator water pipes were uncovered and very hot. This created a significant risk of accidental burns.
“Water pipes feeding radiators were not all covered and very hot to touch which meant there was a significant risk of accidental harm to people should they come into contact with them.” from the report
Weak management checks
needs fixingDaily checks and other audits had not identified the cleanliness problems, the uncovered pipes or an overheated bedroom. This meant risks were not being identified quickly enough.
“The provider did not have effective systems in place to monitor the cleanliness of the home.” from the report
Missed CQC notifications
needs fixingThe manager had not always told CQC about safeguarding events when required. The necessary notifications were submitted after inspectors raised the issue.
“The manager had not always notified CQC.” from the report
- 01How have you kept the new cleaning schedules and audits working since the inspection?
- 02Have all hot water pipes and other environmental risks been checked and made safe?
- 03How do you now check that staff wear PPE correctly in communal areas?
- 04How do you make sure all safeguarding events are notified to CQC when required?
- 05What progress has been made on the action plan requested by CQC?
This was a focused inspection of Safe and Well-led after an initial infection-control check; the ratings for Effective, Caring and Responsive were carried forward from the previous inspection. This explanation was written from the published report of 15 April 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2020
Amber House - Coventry was rated Good; inspectors found safe, kind and personalised care, with some planned improvements still to complete.
This was an unannounced inspection on 27 November 2019. One inspector spoke with a resident, five staff members and a visiting health professional, and reviewed care, medicines, recruitment and quality records.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, detailed care plans, suitable support with food and healthcare, and activities that reflected people's interests.
The home was clean and well maintained. The registered manager was preparing to retire and was mentoring a new manager to make the change smooth. The report says the overall rating was unchanged from the previous Good rating, published on 15 June 2017.
Safe staffing and medicines
Inspectors found enough staff to meet people's needs and safe systems for storing, administering and checking medicines.
“There was enough staff on duty to support people safely.” from the report
Personalised care
Staff knew people's routines, histories and preferences. Care plans gave staff clear guidance about individual support.
“People had detailed, personalised care plans. Their needs, abilities, life history, and preferences were well documented.” from the report
Kind and respectful support
Staff treated people with kindness, respected their privacy and supported them to do as much as possible for themselves.
“Staff respected people's privacy for example by knocking on their doors and waiting permission to enter.” from the report
Activities and relationships
People could take part in varied activities and were supported to stay in touch with family and friends.
“People benefitted from a variety of activities and events that were available across the service and made accessible to all.” from the report
Quality monitoring
The home used regular audits and action plans to identify and complete improvements.
“An action plan was created from the checks and audits which documented any action needed with dates that the action was due by.” from the report
End of life care plans
minorThe report says the new manager planned to develop end of life care plans further. Families may want to check whether this work has been completed.
“The new manager planned to develop the end of life care plans further.” from the report
Feedback response rate
minorEarlier surveys had a low response rate. The home had started a monthly resident discussion group as another way to collect views.
“The provider had previously sent surveys to people and stakeholders however the response rate was low.” from the report
Planned redecoration
minorPart of the dining room was being redecorated, with plans to redecorate other areas over the following year. Families may wish to ask what work was completed.
“An area of the dining room was being redecorated and the registered manager told us that there were plans to redecorate other areas of the home over the next twelve months.” from the report
- 01How was the change from the retiring registered manager to the new manager completed?
- 02What further work has been done on end of life care plans?
- 03Were the planned redecoration works in other areas of the home completed?
- 04How do you now collect feedback from people and relatives following the low survey response rate?
- 05How are staffing levels reviewed when people's needs change?
This was an unannounced planned inspection covering all five CQC questions, and the report says the previous Good ratings remained unchanged. This explanation was written from the published report of 17 January 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Amber House - Coventry
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- April 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2020Goodstayed GoodSafe: GoodWell-led: Good
- June 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2016Goodstayed GoodSafe: Good
- March 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 31 December 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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