Ambleside

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider successfully developed a strategy and culture which consistently promoted trust and understanding between them and the people using the service and focused on learning and improvement.

Following the last inspection, the provider had taken action to make improvements to the culture of the service. They told us, “It takes time and little steps and eventually it happens.” The manager said there was improvements to the culture, staff wellbeing and communication. Staff said this was led by the manager. The manager told us they had worked with staff to bring about cultural improvements. One staff member said about the home, “Yes, massively improved since last inspection. Everything is so much better since we have had a stable manager.” The manager said they had ‘champions in specific areas’ who took responsibility to learn and develop knowledge, so they could support other staff in key areas. One staff member said they were a ‘champion’, so they looked at staff practice and supported where required to help staff’s knowledge. Learning from the last inspection had been taken, to improve practice and to learn lessons from experiences. One staff member said lessons had been learned in how medicine stocks were stored and recorded, which helped reduce medicines errors. The manager was honest to tell us there was still some work to do, but they had prioritised the most important things, such as addressing the culture and people’s experiences at the home. People and relatives said changes had been made for the better and they felt more informed and involved.

The provider had leaders who fully understood the context in which they delivered care, treatment and support. Leaders did not have the skills and knowledge in some areas of care provision to lead the wider team effectively.

The registered manager left Ambleside in January 2026. The manager told us they came to the home to make improvements, and they told us they had submitted their application to us to become registered. They told us, “When I came, I had a meeting with everybody, and I laid it out how we were going to move forward and said my door is always open.” The manager said they had an ‘open door’ policy so people and relatives could speak with them anytime, instead of waiting for planned meetings.

In this report, we have included staff’s feedback which was management was more approachable, listened, acted and spent time with staff. The manager told us they did long days and nights, by choice, so they could meet and get to know, all staff. Without exception, staff praised the manager. One staff member said, “I have had 4 managers in 3.5 years, and you don’t know who to go to.” They said it was much better now. Staff told us how changes had been made which had improved teamwork and people’s outcomes. The home felt calm, relaxed and people looked comfortable in their surroundings. One staff member told us, “Staff morale is good, it has been really bad at times. It is better and I think that’s good because it reflects on the residents.” Staff felt supported and involved in decisions related to the service. They told us regular staff meetings took place where they could share information and discuss issues relating to the home. In addition, staff had supervision meetings where they could discuss any concerns or issues relating to their role.

Processes to support people and staff to speak up were clear.

When new staff started working at the service, they were provided with the whistleblowing policy so they knew how to raise concerns should they not be addressed effectively by their manager. Staff told us they felt at ease to raise any concerns with the manager and felt confident they would be addressed. Staff knew who to raise concerns with if they felt they were not listened to. A common theme was management was approachable which meant any issues could be addressed more promptly.

The provider did value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

We found no issues with the culture of the organisation in the context of workforce diversity and inclusion. The provider ensured staff and leaders were representative of the population of people using the service. One staff member told us about reasonable adjustments which had been made for them and how they had benefited from this support. The provider ensured there was a diverse staff team to support people’s needs. Mental health support and confidential telephone support helped provide staff, with confidential help to discuss any concerns they had.

The provider did not always have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes.

The provider operated a quality assurance system that saw senior staff, management and operations managers complete a variety of audits and checks. These checks made sure people received a quality service however, we found some audits needed better oversight and scrutiny to provide effective results. For example, a medicine audit only checked a small sample, meaning it could take 9 months before the provider had a true picture of safety of the administration of medicines. This audit did not include oversight of the storage of medicines and application of covert medicines, despite scoring 97% and not identifying the issues we found. A documentation audit was completed yet it had not identified the issues we found related to poor recording of people’s foods, fluid intakes and how people were repositioned. This meant there was a risk people didn’t always receive consistent care. In addition, 1 staff member felt communication was not always effective. For example, team leaders attended a handover meeting at the beginning of their shift and passed any relevant information on to the care staff. One staff member told us, “The team leaders have it (handover meeting) at 8am they come back and tell us bits and it’s not what you need to know sometimes.” Through audits and checks, this had not been identified as an area for consideration or improvement.

We discussed these concerns with the operations manager and regional director who agreed to share our feedback with the provider to see how they could improve. We were shown how the home’s audits were considered as part of the wider quality assurance at provider level, supported by in house quality assurance teams who could look, check and identify any patterns or trends. This gave us some assurance the quality of service was being considered.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Care records confirmed the service worked with other health professionals to ensure people’s needs were met effectively. People were positive about the support they received and described good communication to ensure the delivery of care met their needs. People had confidence in the management of the service and the approachability of the manager. The provider supported community relationships and people and relatives were encouraged to take part in activity sessions with the local and wider community.

The provider did focus on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The provider had ensured learning was identified and acted upon following the last inspection.Staff described how the culture of the service had improved which they felt reflected positively on the level of care people received. Feedback we shared with management was taken on board, and our discussions helped them consider what they needed to improve upon. There was a positive attitude to feedback and following our visit, the manager sent us examples of case studies and lessons learnt where they had acted on our feedback to drive improvement.