CQC report explained · a residential care home
What the CQC found at Ambleside
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, September 2023
Rated Requires Improvement; inspectors found unsafe medicines management, incomplete risk records and weak quality checks.
This was an unannounced, focused inspection on 7 June 2023. Inspectors looked only at Safe and Well-led. They spoke with staff and relatives, observed care, and checked care records, medicines records, recruitment files, training and safety checks.
The home was not always safe. Medicines were sometimes prepared in unnamed pots, guidance for some medicines was unclear, and some risk assessments and fire evacuation plans were out of date. Inspectors also found that quality checks had not identified or fixed these problems.
There were also positive findings. Staffing levels were considered sufficient, recruitment checks were completed, the home was clean, and staff knew people well. Managers and relatives were described as approachable and supportive.
The overall rating changed from Good at the previous inspection, published on 8 August 2022, to Requires Improvement. The Safe and Well-led ratings were Requires Improvement. The other three question ratings were not inspected and carried over from the previous inspection.
Safe recruitment
Recruitment records showed that checks were completed before staff worked with people. Staffing levels, skills and experience were also monitored.
“Staff recruitment records showed staff were recruited safely.” from the report
Clean home and infection control
Inspectors found the home clean and uncluttered. They were assured that infection prevention arrangements were in place.
“The care home looked clean and uncluttered on inspection and the housekeeper was following a schedule of cleaning tasks.” from the report
Staff knew people well
Staff could describe people's likes, dislikes and what upset them. The registered manager also worked regularly alongside care staff.
“When staff told us about the people they provided support to, they clearly knew them well” from the report
Approachable managers
Staff and relatives said managers were supportive and that they could raise concerns. Relatives said they were kept informed about changes in people's wellbeing.
“Staff told us members of the senior management team were approachable and supportive.” from the report
Medicines were not always safe
seriousMedicines for three people were put into unnamed pots before administration. Some medicine guidance was missing or unclear, creating a risk of errors and side effects.
“This placed people at risk of harm from medicine errors.” from the report
Risk records were incomplete
seriousSome risks, including falls and health conditions, did not have completed or updated assessments and care plans. This meant staff did not always have written instructions to keep people safe.
“People were at risk of not receiving the support they needed to keep them safe, because their risks were not always suitably assessed or reassessed when their needs changed.” from the report
Fire evacuation plans needed updating
needs fixingTwo people's personal emergency evacuation plans did not contain sufficiently up-to-date information. One had not been completed since admission, and another had not been updated after mobility declined.
“One person's personal emergency evacuation plan (PEEP) had not been completed since admission” from the report
Quality checks missed problems
seriousThe provider's audits had not identified the medicines and risk-management shortfalls. Improvement actions were not always recorded as completed, and a recommended service improvement plan had not been adopted.
“The provider did not have effective systems and processes in place to effectively assess, monitor and improve the quality and safety of the service.” from the report
- 01How have you stopped medicines being prepared in unnamed pots, and how are staff's medicine competencies now checked?
- 02How do you make sure risk assessments and care plans are reviewed promptly when a person's needs or mobility change?
- 03Have all personal emergency evacuation plans been completed and updated, and what support would my relative need in a fire?
- 04What system do you now use to record improvement actions and confirm that they have been completed?
- 05What progress has been made on the action plan requested by CQC?
This was an unannounced focused inspection of Safe and Well-led only; the other three question ratings were carried over from the previous inspection. This explanation was written from the published report of 30 September 2023 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, August 2022
Ambleside is rated Good; inspectors found improved safety and management, with some improvements still needing to be sustained.
This was an unannounced focused inspection on 29 June 2022. Inspectors spoke with seven people, one relative and staff. They reviewed care records, medicines records, recruitment checks, training records and quality audits.
The inspection looked only at Safe and Well-led. Both were rated Good. Inspectors found that risk assessments, infection control and quality monitoring had improved. People had an alternative way to call staff while the old call bell system was being replaced.
The overall rating changed from Requires Improvement to Good. This was because the home had acted on the previous inspection's concerns and was no longer in breach of Regulations 12 and 17. Inspectors recommended keeping a central record of improvement actions.
Improved risk management
People's risk information had been reviewed and updated. Managers were checking whether risk controls continued to work.
“People's risks assessments and associated care plans had been reviewed and amended to ensure staff had up to date information on how to effectively reduce and manage people's risks.” from the report
Infection control
Inspectors found that staff were following the infection prevention and control guidance in place at the time. They were assured that outbreaks could be prevented or managed.
“We were assured that the provider was making sure infection outbreaks could be effectively prevented or managed.” from the report
Safe medicines practice
Medicines were managed safely, including medicines given covertly. The home had learned from a previous medicines error and improved its checking process.
“People's medicines were managed safely including those which were administered covertly (hidden in food or drink).” from the report
Enough trained staff
Inspectors found enough staff to meet people's needs. Recruitment checks included employment references and DBS checks.
“There were enough staff deployed to ensure people's needs were met.” from the report
Respect for choices
Staff asked people's permission before providing care and tried again later when care was refused. The service was working within the principles of the Mental Capacity Act.
“Staff obtained people's permission before delivering care and when people refused care, staff approached the person again later to gain the person's agreement to receive care.” from the report
No single improvement record
minorThe home did not have one central plan showing every improvement action, who was responsible, the deadline and the completion date. Inspectors made a recommendation about this.
“A central service improvement plan, containing all identified actions for improvement, had not been adopted by the service.” from the report
Mixed views on food and activities
minorPeople did not all agree about the food or social activities. The provider had asked for feedback and followed up the comments.
“People had mixed views of the food provided and social activity opportunities.” from the report
- 01Has the old call bell system now been replaced, and what happens if a pager does not work?
- 02How do you record and follow up all improvement actions now that inspectors recommended a central service improvement plan?
- 03What changes have you made in response to people's mixed views about food and social activities?
- 04How do you check that updated risk assessments still match each person's current needs?
- 05What improvements from the previous inspection have you checked recently to make sure they have been sustained?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 6 August 2022 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
7 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- September 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2022Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2022Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- November 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Requires improvement
- November 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017Requires improvementdown from GoodSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- September 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- July 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 23 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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