CQC report explained · a residential care home
What the CQC found at Ambassador House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about visitor safety, admissions, testing, outbreak management and the infection prevention policy. They were only somewhat assured about social distancing, ventilation, infection control audits and some PPE practices.
- Effective?
- Good
- This question was not assessed in this targeted inspection.
- Caring?
- Good
- This question was not assessed in this targeted inspection.
- Responsive?
- Good
- This question was not assessed in this targeted inspection.
- Well-led?
- Requires improvement
- This question was not assessed in this targeted inspection.
What inspectors found, April 2021
Inspected but not rated; inspectors found good COVID-19 controls but concerns about distancing, ventilation, audits and PPE use.
This was an announced, targeted inspection on 18 March 2021. Inspectors checked infection prevention and control arrangements during the COVID-19 pandemic. The home had 23 people living there and could support up to 25 people.
Inspectors found good practice around safe entry and exit, visits, testing, isolation plans and supplies of personal protective equipment. They were assured that visitors were being kept safe, people were admitted safely and outbreaks could be prevented or managed.
The home was inspected but not rated. Inspectors were only looking at infection prevention and control measures, so this report does not provide a full rating of the home or of other areas of care.
Safe visiting arrangements
The home had plans to support relatives to visit safely under new government guidance.
“Staff and professionals entered and left the home in a safe way.” from the report
Testing and isolation
There were arrangements for regular COVID-19 testing and for people to isolate if they had symptoms or a positive test.
“There were plans to support people to isolate if they had a positive test result or showed COVID-19 symptoms.” from the report
PPE supplies and training
Staff had received PPE training and the manager had good supplies available.
“Staff had received training in relation to wearing personal protective equipment (PPE).” from the report
Infection prevention arrangements
Inspectors were assured that the home was managing admissions, visitors, testing and possible outbreaks safely.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Lounge ventilation and distancing
needs fixingSocial distancing was not being promoted in the main lounge, and the room was not well ventilated. The layout was not being used to encourage distancing.
“In the main lounge social distancing was not being promoted and the room was not well ventilated.” from the report
Incomplete infection control audit
needs fixingThe home was clean, but possible infection control risks were not identified and addressed. Inspectors found that the infection control audit was not completed effectively.
“The infection control (IPC) audit was not effectively completed.” from the report
PPE practice
needs fixingSome staff did not wear face masks correctly or always dispose of PPE safely. The manager said they were addressing these shortfalls.
“Some staff did not wear their face masks correctly and always dispose of their PPE safely.” from the report
- 01What changes have you made to improve ventilation and social distancing in the main lounge?
- 02How do you now identify infection control risks and make sure actions are completed?
- 03How do you check that all staff wear face masks correctly and dispose of PPE safely?
- 04How are relatives supported to visit safely under the current visiting arrangements?
- 05What happens if a resident develops COVID-19 symptoms or receives a positive test result?
This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; the home was inspected but not rated and the other areas of care were not assessed. This explanation was written from the published report of 14 April 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2019
Rated Good overall, but inspectors found weaknesses in leadership and quality checks.
Inspectors visited without notice on 27 November 2019. They spoke with people, relatives, staff and the manager. They observed care, reviewed six people's records, medicines records, complaints, staff checks and safety checks.
The home was rated Good for Safe, Effective, Caring and Responsive. People appeared happy and relatives reported real improvements since the new manager started. Inspectors found enough staff, kind care, suitable food and regular activities.
Well-led was rated Requires Improvement. Audits had not always found problems, including incomplete safety checks, weak induction checks for new staff and some poor staff practice. The home had improved since the previous inspection and was no longer in breach of regulations.
Kind and respectful care
Inspectors saw staff supporting people in a kind and thoughtful way. People's privacy and dignity were protected.
“During this inspection we saw staff supporting people in a kind and thoughtful way.” from the report
Improved staffing
Inspectors found enough staff during the visit. Relatives and staff said these were the usual staffing levels.
“I had concerns about a lack of staff some time ago, but not anymore, there's always good staffing when I visit.” from the report
Food and drinks
People were offered choices, favourite foods, snacks and drinks. Staff supported people safely when they needed help to eat.
“There was a plentiful arrangement of snacks offered at mid-morning and a snack and drink station which people helped themselves to.” from the report
Activities and atmosphere
People took part in music, dancing, outings, celebrations and other activities. Inspectors found a lively social atmosphere.
“There was an upbeat atmosphere at the home.” from the report
Improvements since the previous inspection
The report says the standard of care and accommodation had improved following the previous two inspections. Relatives also described improvements since the new manager started.
“Since the new manager has come, things have changed.” from the report
Quality checks missed problems
needs fixingThe manager and provider's audits did not always identify shortfalls. Inspectors had to prompt action on some environmental and care issues.
“The registered manager and the provider's auditing systems used to test the quality of the service were not always effective at identifying shortfalls and areas which needed to be improved upon.” from the report
Fire safety checks
seriousSome checks on fire doors and windows were incomplete. One fire exit did not close fully, and the alarm had been switched off.
“Some safety checks were not complete in relation to fire doors and windows.” from the report
Support for new staff
needs fixingNew staff lacked direction and did not receive competency checks during their three-month induction. Inspectors saw examples of practice that needed improvement.
“New staff did not receive competency checks during their three month induction, to check how they were doing.” from the report
Person-centred practice
needs fixingSome staff did not routinely talk with people. Bedroom signs directing staff about care tasks were not person-centred.
“Staff did not routinely chat and talk with people.” from the report
Some records needed improvement
needs fixingSome mental capacity assessments did not explain how decisions had been assessed. Some end of life wishes had also not been explored.
“Some of these were good at showing how the person had been assessed if they could make certain decisions. Others lacked this information.” from the report
- 01How do you now check and support new staff during their three-month induction?
- 02What action was taken to repair the fire exit door, check the windows and restore the alarm?
- 03How do your current audits identify problems in care practice, equipment and the environment?
- 04How are mental capacity assessments checked to make sure they explain how decisions were assessed?
- 05How do you involve people and their relatives in plans for the garden, furniture and other purchases?
This was a planned, unannounced inspection covering all five CQC questions, with observations, conversations, record checks, medicines checks, recruitment checks and safety checks. This explanation was written from the published report of 18 December 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Ambassador House
5 rated inspections over 4 years: the service has held its Good rating throughout.
- April 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- December 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- November 2016Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- December 2013
Report published without a new overall rating.
- July 2012
Report published without a new overall rating.
- July 2011
Registered with the Care Quality Commission on 27 July 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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