CQC report explained · a residential care home
What the CQC found at Ambleside Bank Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, effective safeguarding, suitable risk assessments and safe medicines management. The home was clean and infection control procedures were effective.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Inspectors found regular audits, action plans and meetings to monitor quality and improve care. People, relatives and staff described management as open, approachable and supportive.
What inspectors found, January 2024
Ambleside Bank Care Home was rated Good; inspectors found safe care and strong management, but there was no registered manager in post.
Inspectors visited on 10 and 12 January 2024. The first visit was unannounced. They spoke with people, relatives and staff, and checked care plans, risk assessments, medicines records, safety records, recruitment records and management audits.
The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe medicines practice, good infection control and suitable safeguarding arrangements. Accidents, incidents and falls were recorded and reviewed for lessons.
People, relatives and staff spoke positively about the home and its management. The inspection was focused only on Safe and Well-led. The other parts of the overall Good rating were carried forward from the last comprehensive inspection.
Staffing and safeguarding
There were enough staff to meet people's needs and keep them safe. Staff had safeguarding training and knew how to report concerns.
“Enough staff were deployed to keep people safe and meet their needs.” from the report
Medicines and records
People received medicines on time and as prescribed. Administration was clearly recorded, including arrangements for medicines given when needed.
“People received their medicines on time and as prescribed, with administration clearly recorded.” from the report
Cleanliness and infection control
Inspectors found the home clean, with up-to-date infection control policies and effective cleaning arrangements.
“The home was clean with effective cleaning and infection control processes in place.” from the report
Listening to people
The home sought people's views through meetings and surveys. It shared updates about actions taken in response to feedback.
“Meetings included a review of actions taken since the last meeting, so people could see their wishes or requests had been met.” from the report
Quality monitoring
The provider used audits, meetings and action plans to monitor the service and identify improvements.
“Action plans were used to identify areas for improvements. These were updated regularly to record progress made.” from the report
Registered manager application
minorThere was no registered manager in post during the inspection. The current manager had applied to register, but the application was still being assessed.
“At the time of our inspection there was not a registered manager in post.” from the report
- 01What is the current position of the manager's application to become registered?
- 02How do you currently check the quality of care in the areas not inspected in this report, especially Effective, Caring and Responsive?
- 03How do you use accident, incident and falls reviews to prevent similar events happening again?
- 04How do you make sure staffing levels increase if people's needs change?
- 05How do you show people and relatives what action has been taken after feedback?
This was a focused inspection of Safe and Well-led only; the other ratings used for the overall Good rating were carried forward from the last comprehensive inspection. This explanation was written from the published report of 25 January 2024 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, March 2021
Inspected but not rated; the previous Good rating remained, but inspectors found infection-control and menu improvements were needed.
This was a targeted inspection on 11 February 2021. Inspectors looked at concerns about food, weight loss and infection control. They spoke with four residents and four staff, and checked five care files and related records.
The home followed government infection-control guidance and had enough personal protective equipment. However, only half the staff had completed the latest local authority infection-control training, and cleaning of frequently touched areas was not recorded. Inspectors suggested extra measures, including fuller visitor screening and better records.
People said they had enough food and drink. Weights were monitored and referrals were made when people lost weight. However, some people did not like the available meals, had limited alternatives, and had not been involved in menu planning. The home was inspected but not rated, so the previous overall Good rating remained unchanged.
Infection-control supplies
The home had enough PPE and carried out regular checks of the environment and hand hygiene.
“The home had a plentiful supply of PPE and completed regular audits of the environment and hand hygiene practice.” from the report
Weight monitoring
People's weights were monitored and referrals were made to professionals when unplanned weight loss occurred.
“Where unplanned weight loss had occurred, referrals had been made to the necessary professionals.” from the report
Food and drink records
The home kept detailed records of what people ate and drank and monitored their weight in line with guidance.
“Detailed records of what people had eaten and drank had been kept, with their weight monitored in line with guidance.” from the report
Hand hygiene checks
The home used an ultraviolet light system during handwashing training and checks to identify areas that had not been washed properly.
“The system identified areas of the hand which had not been washed sufficiently.” from the report
Incomplete current training
needs fixingOnly half the staff had completed local authority infection-control and PPE training. Some staff had last completed infection-control training before the pandemic, so their knowledge of current practice could be limited.
“This meant their knowledge of current best practice would be limited.” from the report
Cleaning records
needs fixingCleaning had increased, but the home could not confirm that frequently touched areas had been cleaned because this was not recorded.
“However, the cleaning of frequent touch points had not been documented, so we were unable to confirm this had been done.” from the report
Visitor screening
minorVisitors were screened and given PPE, but additional best-practice measures such as temperature checks were not used.
“However, additional best practice measures such as temperature checks were not completed, as these were not part of the provider's current policy and procedures.” from the report
Limited meal choices
needs fixingSome people did not like the available meal and softer-food alternatives were not routinely prepared. Residents had not been involved in menu changes or planning future menus.
“People had not been involved in discussions around menu changes, or in generating ideas for future menus, once normal service resumed.” from the report
Malnutrition screening
needs fixingThe malnutrition screening tool was not completed monthly for every person, although weights were monitored and referrals were made when needed.
“The Malnutrition Universal Screening Tool (MUST) which is a five-step tool used to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese was in use, albeit not completed monthly for every person.” from the report
- 01Have all staff now completed up-to-date infection-control and PPE training?
- 02How do you record cleaning of frequently touched areas, and can families see that these checks are completed?
- 03How are residents involved in choosing meals and planning menus?
- 04How do you make sure the malnutrition screening tool is completed monthly for every resident?
- 05What extra visitor screening measures are now used?
This was a targeted inspection of specific concerns about nutrition, weight management and infection control, so the Safe and Effective ratings were not reviewed and the previous Good rating remained. This explanation was written from the published report of 13 March 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.
Every inspection of Ambleside Bank Care Home
3 rated inspections over 7 years: the service has held its Good rating throughout.
- January 2024Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2021Inspected but not ratedSafe: Inspected but not ratedEffective: Inspected but not rated
- June 2018Goodstayed GoodSafe: GoodWell-led: Good
- August 2016GoodSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Report published without a new overall rating.
- September 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 15 December 2010.
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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