Enter and view: Amberley Care Home

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Summary of report content

Healthwatch Dudley undertook an announced enter and view visit on 15 April 2016 to Amberley Care Home.  They spoke to 19 people.

The visit followed earlier concerns and changes at the home since a previous informal visit in 2023, and the Care Quality Commission (CQC) had rated the home as “Inadequate” in November 2025 due to significant failings in safety, leadership, and care quality. 

The CQC found serious issues, including poor risk management, unsafe medication practices, inadequate staff training, and weak safeguarding procedures. Systems to meet residents’ legal rights under the Mental Capacity Act were not reliable, and quality assurance processes were inconsistent. However, staff were generally described as caring and supportive, and many residents said they were treated as individuals. 

Residents generally felt the home was clean and comfortable, although some concerns were raised about maintenance issues such as unreliable lifts, lack of hot water, and the need for redecoration. 

Most residents said they felt safe and staff responded quickly to requests for help, but some reported occasional issues, such as other residents entering rooms at night or staff not always checking concerns. 

Activities had increased compared to the past, but they were often limited and sedentary, and mainly required residents to leave their rooms. Some residents said they felt bored, wanted more variety, and would prefer opportunities to go outside, spend time in the garden, or take part in more meaningful activities. 

Food was generally well regarded, with residents praising the quality and the chef, but many wanted greater variety and more flexibility in portion sizes. Awareness and use of the snack station were low. 

While some residents were supported to be independent, others felt they had limited involvement in decisions about their care. Only around half of respondents said they were involved in care planning, and some reported delays in receiving personal care due to staff being busy. 

Feedback about staff was largely positive, with residents describing them as kind and responsive, although experiences varied and some noted staff shortages or that staff were often busy. Communication with residents and families was generally good, but there were isolated concerns, such as delays in informing relatives about hospital admissions. 

Healthwatch made recommendations to improve residents’ quality of life, including providing more varied and accessible activities, increasing food choice, and improving communication—especially during periods of organisational change. 

In response, the provider acknowledged the findings and stated that improvements were already underway, including enhancing activities, revising menus, strengthening care planning, and improving governance and communication. They emphasised that the home was undergoing significant transition but is working with partners to deliver sustained improvements

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General details

Local Healthwatch
Healthwatch Dudley
Publication date
Date evidence capture began
Date evidence capture finished
Key themes
Access to services
Building, Decor and Facilities, including health and safety
Caring, kindness, respect and dignity
Cleanliness, Hygiene and Infection Control
Communication with patients; treatment explanation; verbal advice
Consent, choice, user involvement and being listened to
Food, nutrition and catering
Lifestyle and wellbeing; wider determinants of health
Patient/resident safety
Privacy and confidentiality
Staffing - levels and training

Methodology and approach

Was the work undertaken in partnership with another organisation?
No
Primary research method used
Observation (eg Enter and View)
If an Enter and View methodology was applied, was the visit announced or unannounced?
Announced

Details of health and care services included in the report

Details of health and care services included in the report
Care home

Details of people who shared their views

Number of people who shared their views
19
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