Amberley Hall Care Home

Updated 5 October 2023

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. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Consisted of 2 inspectors, 1 specialist medicine inspector and 2 Experts by Experience (ExE). An ExE is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Amberley Hall Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Amberley Hall Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used other information we hold about the service, and sourced feedback from the local authority quality assurance team. We used all of this information to assist us with our inspection planning.

During the inspection

We spoke with members of staff including the registered manager, deputy manager (who was also the service’s clinical lead) 2 members of nursing staff, 5 care, 1 team leader, 3 ancillary staff and a member of activities staff. We spoke 13 people living at the service and observed care provided in communal areas. We spoke with 11 relatives about the care and support provided.

We reviewed a range of records, including 8 people's care records and 19 medication records and observed some of the morning medicines round. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

We continued to seek clarification from the provider to validate evidence found.

Updated 5 October 2023

About the service

Amberley Hall Care Home is a service providing nursing and residential care to up to 106 people. The service provides support to people with nursing and residential support care, including for people living with dementia. At the time of our inspection there were 97 people using the service.

The service consisted of 6 units, called Buckingham, Kensington, Sandringham, Balmoral, Windsor and Regency. Each unit was providing either nursing, nursing for people living with dementia, residential care or residential care for people living with dementia. Regency unit was used for people recently discharged from hospital. Staff in this unit worked in partnership with other healthcare professionals, some of whom were based on the unit, to aid people's recovery.

People’s experience of using this service and what we found

Standards of care and support were found to be poor, particularly on the dementia nursing unit. People were not consistently supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We found examples of restrictive practices in use at the service, with a lack of consideration of least restrictive alternatives.

People did not receive their medicines as prescribed, and we identified gaps in the completion of corresponding records. People were not being protected from the risk of harm, including in the condition and cleanliness of the care environment. People had unsupervised access to items such as razors and personal care products, including prescribed creams placing people at risk, particularly those people living with dementia who were reliant on staff support and oversight to keep them safe.

People were not supported with regular repositioning to prevent them developing pressure ulcers. Where people were at known risk of falls, or at risk of leaving the service without staff being aware, the corresponding records showed gaps in the frequency of welfare checks being completed. People’s basic standards of personal hygiene and presentation were not being consistently met, with areas of the service found to have malodour, and some people found to have unclean nails and teeth.

Response times to call bells and assistive technology to maintain people’s safety was poor. Where people were involved in incidents, sufficient mitigation was not being implemented or followed by staff to prevent the risk of reoccurrence. People were not being supported by sufficient numbers of staff, and this was reinforced by people and relative’s feedback.

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

Rating at last inspection and update

The last rating for this service was good (published 17 September 2021).

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

This inspection was prompted by a review of the information we held about this service and due to receiving information of concern relating to the safety of people living at the service. A decision was made for us to inspect and example those risks. We undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Amberley Hall Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to consent, protecting people from the risk of harm or abuse, providing safe care, the governance and oversight of the service, and the number of staff on shift at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.