CQC report explained · a residential care home
What the CQC found at Amberley Care Home
Rated Inadequate: inspectors found the home performing badly and the CQC has taken enforcement action.
What inspectors found, May 2023
Rated Requires Improvement; inspectors found unsafe medicine and risk-management practices and inadequate leadership.
This was an unannounced, focused inspection on 5 October 2022. Three inspectors spoke with staff and reviewed care records, medicine records, recruitment files and management records. They also checked infection prevention and control.
The inspectors found that medicines were not always managed safely. Care records did not always explain how to manage known health risks, including pressure damage, wounds, medical equipment and distress. The home had enough staff, and people said they felt safe.
The overall rating remained Requires Improvement. Safe and Effective were rated Requires Improvement, while Well-led fell from Requires Improvement to Inadequate. The inspectors found breaches of Regulations 12 and 17, and imposed conditions on the provider's registration.
Staffing
Inspectors observed enough staff to meet people's needs. Staff recruitment checks were also carried out.
“We observed there were enough staff to meet people's needs.” from the report
People felt safe
People told inspectors they felt safe. Staff had safeguarding training and knew how to recognise and report abuse.
“People told us they felt safe living at the home.” from the report
Food and drink
People were supported with their diet and fluid intake. Staff involved outside professionals when there were concerns.
“People were supported to eat and drink, and to maintain a healthy diet.” from the report
Working with professionals
Staff worked with healthcare and other professionals, and records showed the outcome of professional visits and any required actions.
“Staff worked with other agencies to support people to live healthier lives.” from the report
Medicine safety
seriousGuidance for as-needed and topical medicines was incomplete. Reasons for giving as-needed medicines were not always recorded, and there were unexplained gaps in some records.
“People's medicines were not always managed and administered safely which placed people at risk of harm.” from the report
Care records and known risks
seriousRecords did not always explain how staff should manage important health needs, such as pressure damage, wounds, medical devices or distress. This increased the risk of avoidable harm.
“We were not assured risks to people were assessed, monitored and managed appropriately.” from the report
Quality checks
seriousThe provider's checks did not identify or fix repeated problems with medicines, accidents, care records, call bells and legal safeguards.
“The provider's systems and processes to monitor and improve the quality of the service were not effective.” from the report
Dementia-friendly environment
needs fixingThe environment had not been adapted to support people living with dementia, their wellbeing or their independence. The provider was advised to consider current guidance.
“The environment was not dementia-friendly and did not promote the wellbeing and independence of people living with dementia.” from the report
- 01What changes have been made to the guidance and records for as-needed and topical medicines?
- 02How are staff now told about and supported to manage each person's specific health risks?
- 03How do you check that accidents, incidents and call-bell response times are reviewed and acted on?
- 04How do you make sure mental capacity assessments and Deprivation of Liberty Safeguards authorisations are current?
- 05What changes have been made to make the environment more suitable for people living with dementia?
This was a focused inspection of Safe, Effective and Well-led; Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 26 May 2023 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 2022
Amberley Care Home rated Requires Improvement; inspectors found kind care, but serious gaps in infection control, risk management and oversight.
Inspectors visited without warning on 29 and 30 November 2021. They spoke with seven people, three relatives, six staff members and one professional. They reviewed care records, medicine records, recruitment files and management records.
The home was not always safe. Government COVID-19 guidance was not fully followed. Risk assessments and care plans were missing or incomplete, some medicine records were not accurate, and recruitment checks were not in place for all staff.
The home was also not well-led. Its checks and audits had not found or fixed important problems. The service had been rated Requires Improvement at the previous inspection and had held this rating for four consecutive inspections.
The inspection looked only at Safe and Well-led. Those areas were both rated Requires Improvement. Ratings for the other areas were carried over from the previous comprehensive inspection, so this report does not provide fresh findings about them.
Kind interactions
Inspectors saw some kind and caring interactions. People and relatives spoke positively about staff and the new manager.
“People and relatives spoke highly of the staff and the new manager.” from the report
People felt safe
People told inspectors they felt safe and staff understood safeguarding procedures.
“I feel safe living here and the staff are lovely and kind.” from the report
COVID testing and vaccinations
People and staff were tested regularly for COVID-19 and had been supported to have vaccinations.
“People and staff were being tested for COVID-19 regularly and had been supported to have COVID-19 vaccinations.” from the report
Some immediate action
The provider acted during the inspection to secure hazardous substances, fit locks, cover hot pipes and adjust fire doors.
“The provider took action during the inspection to start driving improvements on matters that were brought to their attention.” from the report
Infection control gaps
seriousCOVID-19 guidance was not fully followed. There was no system for taking temperatures, and some risks linked to vulnerable people and shared items had not been managed.
“Government guidance on IPC was not always being followed.” from the report
Incomplete risk planning
seriousSome people had identified risks without care plans or risk assessments explaining how staff should keep them safe. These included nutrition, weight loss, sore skin and moving between bed and wheelchair.
“Risk's to people's safety were not always assessed and action taken to manage identified risks.” from the report
Unsafe records and medicines
seriousMedicine audits had missed an error where a medicine was not given as instructed. Handwritten records were not always signed or checked, and allergies were not recorded on medicine administration records.
“Audits of medicine management had failed to identify that a person's medication was not been given as instructed as specified in the patient safety instructions.” from the report
Weak governance
seriousThe home's audits did not identify important safety hazards, recruitment gaps or failures to follow infection control procedures. Inspectors found this was a breach of the governance regulation.
“Systems in place to monitor and improve the quality of the service were not effective.” from the report
Recruitment checks
seriousRequired checks confirming that all staff were suitable to work in care were not in place.
“Staff without the appropriate checks in place to confirm their suitability of working in care, had been employed.” from the report
- 01What has been done to create and regularly review risk plans for nutrition, weight loss, sore skin and moving between bed and wheelchair?
- 02How are you now checking temperatures, COVID-19 risks and infection control for people, staff and visitors?
- 03Have all staff recruitment checks now been completed, and how are these checked and audited?
- 04What changes have been made to medicine records, including recording allergies and checking handwritten entries?
- 05How are you checking fire doors, hazardous substances, hot pipes and staffing levels at night?
This was an unannounced focused inspection of Safe and Well-led only; the other key question ratings carried over from the previous comprehensive inspection. This explanation was written from the published report of 27 January 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.
Every inspection of Amberley Care Home
6 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- January 2022Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- January 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodWell-led: Requires improvement
- March 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Inadequate
- December 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2013
Report published without a new overall rating.
- January 2013
Registered with the Care Quality Commission on 18 January 2013.
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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