Amber Home Carers Surrey

Date of Inspection: 28 October 2025 to 19 November 2025. Amber Home Carers Surrey provides personal care to people in supported living settings and older people living in their own homes. This report is in relation to the supported living settings, which at the time of our assessment were provided across 9 separate locations. During our assessment we visited 5 of those settings. The service is also registered to provide treatment for disease, disorder or injury. However, the provider told us they were not utilising this part of their registration. There was a registered manager in post who was also the Nominated Individual for the service. They are referred to as the provider throughout the report. The assessment was carried out to review reports of concerns regarding people’s care, including their safety, the management of incidents, safeguarding, staff skills, and the maintenance of their dignity. During our assessment we identified breaches of legal regulations in relation to managing risks to people’s safety, medicines management, providing person centred care in line with best practice, treating people with dignity and respect, staff skills and knowledge and the overall governance of the service. We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choice, independence, and good access to local communities, which most people take for granted. We found both the management and staff teams lacked understanding of this and other best practice guidance. This meant people’s needs, preferences, aspirations and outcomes were not reviewed in line with the guidance, and they were not supported to have as ordinary a life as possible. Risks to people’s safe care and treatment were not robustly assessed, and there was a lack of guidance for staff to follow. Care plans lacked essential information about people’s individual needs, such as how their anxiety presents, what triggers distress for them, and the specific strategies that help to support them. Accidents and incidents were not consistently reviewed, and there was limited evidence that appropriate actions were taken to reduce the risks identified. We identified in excess of 40 cases where safeguarding concerns were not reported externally in line with required procedures. This lack of oversight meant that people and staff did not receive timely support or opportunities to learn from incidents, which contributed to an environment where concerns were not openly recognised or addressed. There was a lack of guidance regarding people’s health care needs. Staff were not always aware of people’s health care conditions, the support they required to manage them or when referrals to healthcare professionals should be made. Systems to manage people’s medicines safely were not robust and records were not reviewed to identify concerns. People’s support was not effective as systems and processes were not implemented to ensure robust assessments, support planning and review. Complaints and concerns were not recorded to enable trends to be identified and issues to be reviewed. Although staff told us they felt supported in their roles, we found there was a lack of structured guidance and supervision to monitor their practice and ensure they received the training they required. There was a lack of overall governance with no audits being completed in areas including medicines, care records, staff management, safeguarding or accidents and incidents. This meant that shortfalls in the care and support people and staff received had not been identified and acted upon. Following our assessment the provider assured us they had completed a review of the systems in place and had implemented a range of processes which they considered would improve the service people received. This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.

Amber Home Carers improved from Requires Improvement to Good following a focused inspection, having remediated prior breaches of Regulations 11, 12, and 17 relating to consent, medicines management, and governance. The service demonstrated strong person-centred care and effective partnership working, with minor areas for improvement around family communication and consolidation of electronic care records.

Amber Home Carers received an overall Good rating at its first inspection, with Safe rated Requires Improvement due to inadequate staff recruitment checks, specifically reliance on personal rather than professional references for the majority of care workers. All other key questions were rated Good, reflecting a person-centred, well-managed service where people and relatives reported positive experiences.

Amber Home Carers received an overall rating of Requires Improvement at this May 2023 inspection, with breaches of Regulations 11, 12 and 17 identified relating to consent, safe medicines management, risk assessment, and governance failures. The service demonstrated genuine strengths in caring, responsiveness and staffing stability, but systemic gaps in oversight, record-keeping, mental capacity assessments and medicines management posed risks to people's safety.