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CQC report explained · a nursing home

What the CQC found at Ambika Lodge Care Home

Goodpublished 15 April 2021, 5 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
Inspectors found that risks were assessed, staff understood safeguarding procedures, staffing and recruitment were safe, and medicines were generally managed safely. One recent administration error was identified and corrected immediately.
Effective?
Good
This question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
Caring?
Good
This question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
Responsive?
Good
This question was not inspected during this visit. Its previous rating was used in calculating the overall rating.
Well-led?
Good
The home had a registered manager, regular quality checks and a positive atmosphere. Inspectors found that concerns and improvements were acted on promptly.
The latest report, explained

What inspectors found, April 2021

Ambika Lodge Care Home was rated Good; inspectors found safe care and strong management, with one recent medicines error corrected straight away.

This was an unannounced focused inspection on 24 March 2021. Inspectors looked at Safe and Well-led after concerns about safeguarding and infection control. They spoke with people, staff and relatives, observed care, and checked care, medicines, recruitment and management records.

The home was rated Good for Safe and Well-led. Inspectors found safeguarding procedures, risk assessments, staffing, recruitment and medicines systems were generally safe. They were also assured that infection control measures were in place for visitors, testing, personal protective equipment and possible outbreaks.

One recent medicines administration error was found. The manager corrected it immediately. The home had regular checks and acted when they found areas needing improvement.

This inspection did not reassess Effective, Caring or Responsive. The previous ratings for those areas were carried forward when calculating the overall Good rating.

What inspectors praised
  • Risk management

    Care plans included risk assessments for issues such as falls, mobility and skin damage. Staff had guidance on how to reduce risks and keep people safe.

    “Care plans contained risk assessments for areas such as falls, mobility and skin integrity.” from the report
  • Infection control

    Inspectors were assured that the home had measures for safe visiting, testing, personal protective equipment, hygiene and managing outbreaks.

    “We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
  • Management checks

    The home carried out regular checks on care records, medicines, health and safety and infection control. Improvements identified through these checks were addressed quickly.

    “Records showed these checks were carried out on a regular basis and where they had highlighted areas for improvement, these were addressed quickly.” from the report
  • Communication with relatives

    The home used telephone calls, video calls and window visits during the pandemic, and arranged later visits using safety measures.

    “The registered manager told us they had used various communication methods to communicate with people's relatives which included telephone calls, teams calls and window visits during the pandemic.” from the report
What inspectors were concerned about
  • Recent medicines error

    needs fixing

    Inspectors found one medicines administration error shortly before an audit. The manager corrected it immediately, but families should ask what action was taken to prevent a repeat.

    “During the inspection we identified one administration error which had occurred very recently prior to an audit taking place.” from the report
  • Staffing could sometimes feel stretched

    minor

    Inspectors found enough staff overall, but one person said staff were occasionally thin on the ground. Most days, they said, help did not take long.

    “Occasionally thin on the ground but most days someone straight here, we do not have to wait long.” from the report
Questions to ask them, based on this report
  1. 01What caused the recent medicines administration error, and what has changed to reduce the chance of it happening again?
  2. 02How do you check that medicines are given at the right time, especially time-critical medicines?
  3. 03How many staff are usually on duty during the day and at night, and what happens if staffing is short?
  4. 04How are relatives told about concerns, incidents or changes in their family member's care?
  5. 05Which findings from the previous comprehensive inspection remain current, since Effective, Caring and Responsive were not inspected this time?

This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 15 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.

An earlier report, explained

What inspectors found, September 2018

Rated Good; inspectors found safe, kind and responsive care, but Mental Capacity Act checks needed improvement.

This was a comprehensive, unannounced inspection on 14 August 2018. It was the first inspection since the home was registered in September 2017. Inspectors spoke with people, relatives, staff and health professionals, observed care and checked care records, medicines, staffing and management systems.

The home was rated Good overall, with Good ratings for Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines systems, suitable care planning, kind and respectful staff, activities and effective quality checks.

Inspectors recommended that the provider review its use of the Mental Capacity Act. Some bedrail decisions did not have the required mental capacity assessment, and a pharmacist had not been involved in a decision about giving one person's medicine secretly in drinks.

What inspectors praised
  • Enough staff

    Inspectors saw sufficient staff during the visit. People said help came quickly and staff did not seem rushed.

    “There were sufficient numbers of staff to safely meet the needs of people.” from the report
  • Kind and respectful care

    Staff knew people well and supported their dignity, privacy and independence.

    “People were treated with warmth, compassion and respect.” from the report
  • Personalised care

    Care plans recorded people's needs, choices and preferences. They were reviewed when people's needs changed.

    “Care plans were person centred and regularly reviewed to ensure they reflected people's current care and support needs.” from the report
  • Activities and family contact

    The home offered group and individual activities and supported people to stay in touch with their families.

    “People had access to a range of activities which they could be involved with including group and one to one activities.” from the report
  • Positive management

    The management team was visible, approachable and used audits and feedback to monitor the service.

    “The registered manager promoted a positive, person centred culture and demonstrated their commitment and passion to ensuring people living at Ambika Lodge Care Home received good quality care.” from the report
What inspectors were concerned about
  • Mental Capacity Act records

    needs fixing

    Some people using bedrails did not have a recorded mental capacity assessment. One decision to give medicine secretly in drinks had not involved a pharmacist. Inspectors made a recommendation for the provider to review its practice.

    “Some people had bedrails and, although a risk assessment had been completed regarding the use of bedrails, a MCA assessment had not been completed.” from the report
Questions to ask them, based on this report
  1. 01How do you now record mental capacity assessments and best-interest decisions for people using bedrails?
  2. 02If a person's medicine needs to be given secretly in food or drink, how do you involve a pharmacist and record the decision?
  3. 03How will you make sure my relative's care plan is reviewed promptly if their needs change?
  4. 04What activities would be suitable for my relative, including one-to-one activities if they cannot join group activities?
  5. 05How do you check that staffing levels remain enough for the needs of people living here?

This was a comprehensive inspection covering all five areas, and it was the home's first inspection since registration in September 2017. This explanation was written from the published report of 14 September 2018 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.

The story over the years

Every inspection of Ambika Lodge Care Home

2 rated inspections over 3 years: the service has held its Good rating throughout.

  1. April 2021Goodcurrent ratingstayed Good
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Ambika Lodge Care Home →

  2. September 2018Good
    Safe: GoodWell-led: Good

    Read what inspectors found at Ambika Lodge Care Home →

  3. September 2017

    Registered with the Care Quality Commission on 8 September 2017.

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.

Next steps

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