CQC report explained · a nursing home
What the CQC found at Amberley Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, April 2023
Amberley Care Home was rated Good overall; inspectors found safer care and effective support, but management systems still needed to become consistent.
This was an unannounced, focused inspection. Inspectors visited on 15 and 16 March 2023, spoke with people, relatives, staff and health professionals, and checked care records, medicines records and records about how the home was run.
The home was rated Good for Safe and Effective. Medicines were managed more safely, risks were assessed, staffing levels were sufficient, infection control had improved and people were supported with consent, food, healthcare and their individual needs.
Well-led remained Requires Improvement. The new manager and provider had made improvements, but some audits were not meaningful enough and records of repositioning people were not always complete. The overall rating improved from Requires Improvement at the previous inspection because the home was no longer in breach of regulations.
Safer medicines
Medicines records, PRN protocols and medicine stocks had improved. Staff administering medicines had completed training and competency checks.
“Medication administration records were correctly completed, protocols for 'as required' (PRN) medicines were in place and stocks of medicines were better managed.” from the report
Enough trained staff
Recruitment checks were in place and rotas showed enough staff to meet people's needs. Staff received induction, ongoing training and supervision.
“Rotas confirmed there were enough staff employed to ensure people's needs were being met daily.” from the report
Consent and choice
The home had improved its handling of DoLS conditions and mental capacity requirements. Staff asked for consent and involved representatives and professionals in best-interest decisions.
“Records now demonstrated any conditions in place were being met.” from the report
More positive leadership
The new management team was visible and accessible. People, relatives and staff reported improvements in the service and staff morale.
“The new management team promoted a more positive culture in the home.” from the report
Care records were incomplete
needs fixingInspectors were assured that people were being repositioned, but this was not always recorded in the electronic care notes. The manager took action after this was raised.
“Whilst we were assured people received this care, it was not always recorded in electronic care notes.” from the report
Quality checks were not always meaningful
needs fixingSome audits did not identify problems effectively. The report gives the example of a person listed as resident of the day who did not know about it.
“Some of these needed to be more meaningful.” from the report
Improvements need to last
needs fixingThe home had improved, but inspectors could not raise the well-led rating because consistent good practice had not yet been shown over time. New champion roles and other changes still needed to become established.
“The manager was aware recent improvements needed to be fully embedded in staff practice and sustained.” from the report
Some call-bell delays
minorCall bells were answered, but people gave mixed views about how quickly staff responded. Some said they sometimes had to wait.
“Call bells were responded to, although we received some mixed feedback as to the timeliness of the response from staff.” from the report
- 01How do you check that repositioning and other care interventions are recorded every time?
- 02What changes have you made to ensure audits identify real problems rather than just being completed?
- 03How are you checking that recent improvements have become consistent across all shifts and floors?
- 04What is the current average response time to call bells, and how are delays investigated?
- 05When will formal surveys of people and relatives take place, and how will the results be used?
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 20 April 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, December 2022
Rated Requires Improvement; inspectors found kind, responsive care, but problems with medicines, infection control, consent and oversight.
Inspectors visited without warning on 13 and 20 September 2022. They spoke with people, relatives and staff, and checked care records, medicines, training, safety records and how the home was managed.
The home had improved its person-centred care and staffing arrangements. People spoke positively about activities, food and staff support. The responsive rating improved from Requires Improvement to Good.
However, medicines were not always managed safely. Infection control procedures were not always followed. The home had also failed to identify and follow conditions attached to some DoLS authorisations. Its checks and audits had not found these problems.
The overall rating remains Requires Improvement. Safe, Effective and Well-led were rated Requires Improvement. The home had been rated Requires Improvement at the previous inspection too, and has held this rating for two consecutive inspections.
Kind, personalised care
Inspectors saw staff interacting kindly and considerately with people. Care generally reflected individual needs and preferences.
“People received person-centred care which met their individual needs and considered their preferences, although these were not always documented in electronic care plans.” from the report
Activities and social life
People spoke positively about the range of activities. The home had added music therapy and offered trips, quizzes, films and live music.
“One person told us, "They are doing very well with activities, they try hard; there are lots of quizzes.” from the report
Healthcare support
People could access a range of health professionals. Advice from appointments and assessments was recorded and followed.
“People had access to a variety of medical and health related services, such as general practitioners (GPs), speech and language therapists, tissue viability nurses and dieticians.” from the report
Staffing improvements
Staffing levels were allocated using the provider's dependency system, and the previous staffing breach had been removed. Recruitment checks were completed for new staff.
“At this inspection improvements had been made and the provider was still no longer in breach of Regulation 18.” from the report
Medicines
seriousThere were delays in obtaining antibiotics, medicines were not always given at the right times, records were incomplete, and some stock and waste arrangements were unsafe.
“Medicines had not been consistently managed safely. This was a breach of Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Infection control
seriousStaff did not always use the correct protective equipment or wash their hands at the right times. An overflowing bin containing contaminated waste was not dealt with until the end of the second inspection day.
“We observed staff not always donning the correct personal protective equipment (PPE) when entering areas where this was a specific requirement.” from the report
Consent and DoLS conditions
seriousThe home had not identified conditions attached to DoLS authorisations, so it did not ensure those conditions were followed. The manager corrected this after the inspection.
“Conditions attached to DoLS authorisations had not been identified and were not being complied with. This was a breach of Regulation 11 (Consent) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Weak quality checks
seriousThe home's audits and checks did not identify the medicines, infection control and DoLS problems. There had also been little progress in making the environment more suitable for people living with dementia.
“The provider had failed to consistently assess, monitor and improve the quality of the service. This was a breach of Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Communication and recording
needs fixingPeople and relatives said communication could be better. Some preferences and information were not recorded consistently across the home.
“A common theme was communication; people and their relatives considered this could be improved.” from the report
- 01What has changed since the inspection to make sure antibiotics and other time-sensitive medicines are obtained, given and recorded without delay?
- 02How do you now check that staff use the correct PPE, wash their hands properly and deal promptly with contaminated waste?
- 03How are conditions attached to each person's DoLS authorisation recorded, monitored and followed?
- 04What actions have been completed in response to the warning notice about governance, and how will you show that audits now identify problems?
- 05What specific changes are planned to make the home easier for people living with dementia to find their way around?
This was an unannounced inspection covering Safe, Effective, Responsive and Well-led; the report does not give a separate Caring rating, and says ratings for key questions not inspected carry over from the previous inspection. This explanation was written from the published report of 13 December 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
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- April 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- August 2021Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- March 2020
Registered with the Care Quality Commission on 13 March 2020.
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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