CQC report explained · a nursing home
What the CQC found at Amberley Hall Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, October 2023
Amberley Hall Care Home was rated Inadequate and placed in special measures; inspectors found serious problems with safety, staffing, medicines and management.
This was an unannounced focused inspection on 11 July 2023. Inspectors looked at Safe and Well-led only. They spoke with 13 people, 11 relatives and staff, observed care, and checked care, medicines and management records.
The home was not consistently safe. Inspectors found poor medicine records, unsecured medicines and care products, missed welfare checks, poor responses to call bells, unsafe building security, gaps in repositioning, poor cleanliness and not enough staff. They were especially concerned about the dementia nursing unit.
The home was also not well-led. Its checks and audits had failed to find or fix important risks. The overall rating fell from Good at the previous inspection to Inadequate. The home was placed in special measures and CQC said it would be re-inspected within six months unless the provider's registration was cancelled.
Safer recruitment checks
The home completed pre-employment checks, including DBS checks, and provided an induction for new staff.
“The service completed pre-employment checks to ensure staff were safe to work with people living in a care setting.” from the report
Family visits
People and relatives said visitors were welcome indoors, in the gardens and in the local community. Relatives could also stay at lunchtime to support someone with their meal.
“People and relatives confirmed they were welcome to visit the service, and spend time indoors and outside in the gardens” from the report
Complaints were followed up
The manager responded to the five complaints received in the previous 12 months and kept complainants updated during investigations.
“We could see the registered manager responded to each complaint in line with the provider's policies” from the report
Links with health professionals
Staff reported good working relationships with the GP surgery and said they sought help from external professionals when needed.
“Staff worked closely with health and social care professionals.” from the report
People were at risk of harm
seriousDoors and gates did not close securely, and people had previously left without staff knowing. Risk assessments and welfare checks were not consistently followed.
“The care environment was unsecured.” from the report
Medicines were not managed safely
seriousRecords did not always show that medicines were given correctly or at the prescribed dose. Medicines and creams were not always stored securely, and some application records were incomplete.
“People did not receive their medicines as prescribed, and we identified gaps in the completion of corresponding records.” from the report
Too few staff
seriousStaffing levels did not meet people's assessed needs, particularly on the dementia nursing unit. This affected personal care and response times to call bells.
“There were not enough staff to meet people's care needs.” from the report
Poor cleanliness and hygiene
needs fixingSome areas smelled unpleasant and were visibly unclean. Damaged equipment and surfaces made effective cleaning more difficult, and some people's nail and teeth care was not adequate.
“The service was found to be visibly unclean with areas of malodour.” from the report
Weak management oversight
seriousAudits and daily checks did not identify important risks. Actions were allowed to remain unfinished, incidents were not always reported, and lessons were not consistently used to prevent repeat problems.
“The systems and processes to assess, monitor and improve the quality and safety of the service were not established or operated effectively” from the report
- 01How many staff are now working on each unit, especially the dementia nursing unit, and how does this match residents' assessed needs?
- 02What changes have been made to medicine storage, administration records, cream body maps and patch application records?
- 03How have you secured doors and gates and improved response times to call bells and assistive technology?
- 04How are mental capacity assessments and best-interest decisions now recorded, and how do you check that restrictive practices are necessary and least restrictive?
- 05What evidence can you show that audits now identify and resolve cleanliness, safety, staffing and incident-reporting problems?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection. This explanation was written from the published report of 5 October 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, September 2021
Amberley Hall Care Home was rated Good; inspectors found safe, well-managed care, although staffing levels were not viewed consistently by everyone.
Inspectors visited on 23 August and 7 September 2021 without telling the home in advance. They spoke with people, relatives and staff, observed care, checked records and reviewed how the home managed safety and infection control.
The home was rated Good overall. Safe and Well-led were both rated Good, improving from Requires Improvement at the previous inspection. Inspectors found that risks were assessed, medicines were managed safely, infection controls were followed and staff recruitment checks were completed.
People and relatives said they felt safe. The manager monitored incidents, audits and feedback, and used the findings to make improvements. Some relatives and staff felt staffing was tight at busy times, although inspectors found people's needs were met during their visit.
Risks were managed
Care risks, including risks to people's skin, mobility and diet, were recorded and reviewed when people's needs changed.
“Risks to people's health, safety and wellbeing were identified and assessed.” from the report
Safe medicines practice
Inspectors found that medicines were stored, given and disposed of safely, with appropriate records and regular checks.
“Medicines were managed safely, and infection prevention and control procedures were followed.” from the report
Infection control
The home followed measures for testing, protective equipment, distancing, admissions and visits during the COVID-19 period.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Managerial oversight
The manager used audits, surveys and a service improvement plan. Staff felt able to raise concerns and expected action to be taken.
“The registered manager used a variety of tools to monitor and improve the service.” from the report
Staffing at busy times
minorPeople's basic needs were being met, but some relatives and staff said staffing could feel tight, particularly in the morning. One relative reported that a family member sometimes received breakfast late.
“Another told us, "They always seem short of staff. My [family member] got their breakfast at 11am, which is not good as its nearly lunchtime.” from the report
- 01How many staff are planned for each unit during busy morning periods?
- 02How do you respond when staffing is lower than planned or people need to wait for breakfast or personal care?
- 03What are the current ratings for Effective, Caring and Responsive, since these areas were not assessed in this inspection?
- 04How are changes in a person's risks, including mobility, skin or diet risks, passed on to all staff?
- 05How will you keep relatives informed if a person becomes unwell or there is an incident?
This inspection focused on Safe and Well-led, including infection prevention and control; the report does not provide current ratings for Effective, Caring or Responsive. This explanation was written from the published report of 18 September 2021 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 Hall Care Home
7 rated inspections over 8 years: the service has slipped, from Requires improvement to Inadequate.
- October 2023Inadequatecurrent ratingdown from GoodSafe: InadequateEffective: GoodCaring: GoodResponsive: GoodWell-led: Inadequate
- September 2021GoodSafe: GoodWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- February 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2016Requires improvementstayed Requires improvementWell-led: Requires improvement
- March 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- April 2012
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 10 January 2011.
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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Most charge £990 to £1,120 a week. 9 can care for a couple. 14 years' experience on average.
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