Ambleside Lodge - London

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 56 (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 did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

Systems for learning from incidents were not always effective. Although accidents and incidents were recorded and information was shared at handovers, relevant information had not always been transferred into people's care plans and risk assessments. This meant staff returning from periods away from work may not always have easy access to important information about changes in risk. There was evidence the provider shared concerns with social workers and mental health professionals, although people’s care records did not always demonstrate the outcomes of this professional engagement.

Staff understood how to report concerns and described a culture where lessons were discussed and shared. One staff member told us, “We discuss things in our team meetings, and we are told about it when we need to change things.” Another said, “As soon as there is a problem they tell us.” Staff and people told us they would raise concerns with managers or senior staff if required.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

Assessments were completed before people moved into the care home and there was evidence of engagement with referring organisations and professionals involved in people's care. People with changing physical or mental health needs were supported through planned admissions and liaison with external agencies. One person who had recently moved from hospital told us, “I was in hospital before I came. No problems with moving in here.” Staff described effective communication during transitions and said they were advised of people’s needs before they came to live at the home.

The provider did not always share concerns quickly and appropriately.

The provider had not notified CQC about a safeguarding concern as required. Although records demonstrated the concern had been addressed appropriately, the failure to submit a statutory notification reduced external oversight and assurance. The registered manager acknowledged this omission during the inspection.

People consistently told us they felt safe living at the home and knew who they could speak to if they had concerns. One person said, “I would tell the manager if I didn't feel safe.” Another told us, “I go to the office and tell them.” Staff had received safeguarding training and demonstrated a good understanding of abuse risks. One staff member explained, “We need to be aware of changes in behaviour and listen and act on anything they tell us.”

Systems were in place to safeguard people’s finances where the service managed money on their behalf.

The provider did not always ensure people’s risk assessments and management plans fully met their needs.

People’s risk assessments and care plans did not always provide staff with detailed guidance on how risks should be managed. For example, mental health risk assessments focused on crisis responses and did not consistently identify early warning signs of deterioration or explain how staff should support people to reduce anxiety and distress before situations escalated.

People were involved in discussions about their care, wishes and risks through regular keyworker meetings and reviews involving professionals. Staff had received positive behaviour support training and demonstrated a good understanding of individual risks. The registered manager and staff were able to describe strategies they used to support people experiencing anxiety, despite these not always being fully recorded. One staff member said, “It’s important we help people know how to keep themselves safe in the community.”

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment and facilities supported the delivery of safe care.

We identified significant concerns regarding fire safety. We observed fire doors were wedged open because door guards had failed and fire door seals required replacement. These issues had been identified by an independent fire risk assessment in 2025, but no action had been taken to address them, potentially placing people at risk in the event of a fire. We noted a broken window restrictor in an upstairs bathroom. The registered manager told us window restrictors were checked regularly but these checks had not been recorded, so we could not be assured about how long it had been broken. Individual smoking risk assessments were not in place despite concerns relating to one person smoking in their room. The registered manager showed us a general smoking risk assessment for the home, but there were no individual risk assessments for people who smoked.

These concerns demonstrated a breach of legal regulations relating to safe care and treatment.

The provider took immediate action during the inspection and replaced the door guards, door seals and broken window restrictor. Personal emergency evacuation plans were relocated into an accessible emergency “grab and go” bag to improve staff access in an emergency.

The environment was otherwise clean, tidy and suitable for the people living there. Weekly fire alarm checks, fire drills, gas and electrical safety checks and portable appliance testing were all up to date.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider generally maintained safe staffing arrangements. Two staff were available during the day and one at night, with management support available through an on-call system where required. Staffing levels were reviewed in line with people's needs. We asked the registered manager about how the service would manage if there was an emergency at night. They advised us that they and other on call senior staff lived locally and could attend the service immediately to provide support should this be required.

Staff recruitment records demonstrated appropriate pre-employment checks had been completed before staff started work. Induction programmes were completed and signed off. Mandatory training was undertaken and refreshed regularly, with some staff holding additional qualifications. Staff received regular supervision and attended team meetings. Staff members told us there were enough staff available and support from managers was accessible at all times. One staff member said, “Induction was very good. I learned a lot about working here before I started.” Another told us, “Training is mostly online, but it is good and we have refreshers every year.”

People also gave positive feedback about staffing levels. One person said, “There is always someone around when I need them.”

The provider did not always ensure the risk of infection was managed effectively.

At the start of the inspection, we found the supply of hand towels was limited and replacement stock had to be purchased. When we returned to the home there was an improved supply, although disposable towels were not stored within a dispenser. Hand wash was available, but this appeared to be watered down.

The provider maintained a stock of personal protective equipment and staff understood when this should be used. Staff had received infection prevention, control and food safety training. The home held a food hygiene rating of 4 (good). The environment was clean and free from unpleasant odours, and people confirmed this. One person told us, “It is clean.”

Staff demonstrated a clear understanding of infection prevention measures, and one explained, “We have masks, gloves and aprons for giving care and medicines and cooking.”

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Medicines were stored securely and administered by trained staff whose competencies were assessed. Medicines records were accurate.

People understood the purpose of their medicines. Staff monitored refusals appropriately and sought clinical advice when necessary. One person told us, “They tell me when I get it.” Another said, “I know what it is for.” Staff confirmed, “We had training in this. They did a competency check afterwards.” Daily running totals of medicines were introduced during the assessment to strengthen oversight.