Amberley House Care Home

Reviews of people’s needs and risk assessments were not up to date and did not reflect changes in circumstances. The provider did not effectively assess and manage risks to people’s health and safety. Care plans, risk assessments and handover information contained conflicting and inaccurate information and did not give clear guidance for staff. This meant people were not properly involved in managing risks, and staff were not directed to provide care safely.

The principles of the Mental Capacity Act were not always followed to ensure people were not restricted unlawfully. Deprivation of liberty safeguards applications had been submitted for some people, however monitoring of authorised applications was not effective.

Care and treatment were not always delivered in a person centred way, people who were unable to consent to some aspects of their care did not have a detailed care plan to direct staff on how to meet their needs. For example, detailing how staff should respond if a person refused to be repositioned.

During the assessment we observed most areas of the service were clean, however the dining room was cluttered and the fridge required cleaning. Staff did not always follow the provider’s infection prevention and control policy. Personal protective equipment and adequate hand washing was not always used to ensure the spread of infection was reduced.

We found the skill mix of staff varied and at times there was not enough staff to meet the needs of people. The service used agency staff to cover sickness, annual leave and staff vacancies. New members of staff were not always supervised by an experienced member of staff.

Medication records were not completed in full, in line with the provider’s medication policy. Stock amounts were not always recorded and medication to be given ‘as required’ was not always documented to have been offered, taken or refused. This meant people may not have received medication as prescribed.

Systems and processes to monitor the service were ineffective. Audits were not always acted upon when gaps were found, and other areas of the service were not audited to continuously ensure the needs of people were being met. Systems for reviewing and embedding learning were ineffective, meaning lessons from incidents were not consistently applied or sustained.

Processes and systems to hold money for people were effective and all transactions were clearly recorded and audited.

We identified breaches of regulations in relation to person-centred care, safe care and treatment, safeguarding, management of the service and staffing.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

We have asked the provider for an action plan in response to some of the concerns found at this assessment.