Archived: Amber House

Updated 5 December 2019

The inspection: We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Inspection team: The inspection team consisted of two inspectors and an Expert by Experience on the first day of inspection and two inspectors on the second day. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type: This service is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There was no registered manager at this inspection. Services are required to have a manager registered with the CQC. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection: This inspection was unannounced. We told the provider when we would be returning for the second day.

What we did: Before the inspection we reviewed information available to us about this home. This included details about incidents the provider must notify us about, such as abuse; and we sought feedback from the local authority. The provider sent us a provider information return prior to the inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

During the inspection we spoke with the general manager, two senior care workers, two care workers, and the chef. We spoke with seven people who used the service, relatives of four people and three professionals. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We looked at three people’s care records in full and three peoples care plans in part. We reviewed medication administration records and a selection of documentation about the management and running of the service. This included recruitment information for three members of staff, staff training records, policies and procedures, complaints and staff rotas.

Updated 5 December 2019

About the service: Amber House is a residential care home registered to provide accommodation and personal care for up to 44 older people, including those who are living with dementia. At the time of the inspection there were 22 people using the service.

People’s experience of using this service: People were not kept safe from harm. Risk assessments were not up to date, specific or followed by staff to ensure individuals were safe.

Processes and records were not maintained to ensure people always received their medicines safely as prescribed.

Some people told us they had to wait for staff support. We observed staff not meeting people’s needs in a timely way. This had impacted on people’s dignity and showed not all staff had respect for people.

Care was not always person-centred. Some staff had good knowledge about people’s needs but this was not always captured and reflected in care planning. People’s diverse needs were not always considered.

Staff did not receive appropriate training or assessment of their competency to ensure they had the appropriate skills to meet peoples’ individual needs. Lessons had not been learnt from accidents and incidents to reduce the likelihood of reoccurrence.

People, their relatives and health care professionals had mixed views about the care provided. Person-centred care was not reflected within people’s care plans and associated records.

The provider failed to ensure that improvements were made. This is the fifth time the service has been rated overall as below ‘good’ and the provider had failed to deliver on the action plan following the last inspection. There was no registered manager in post at the service.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

Rating at last inspection: Requires improvement (report published June 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Enforcement: CQC took enforcement action and the provider made the decision to close the service.

Follow up: We will continue to monitor the service through the information we receive until we return to visit as per our re-inspection programme. The provider will continue providing regular updates to their action plan. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk.