Ambleside Lodge - London

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 good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to good governance.

This service scored 61 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had a statement of purpose and a values statement. Policies and procedures reflected best practice and staff had opportunities to discuss care, equality and regulatory requirements through supervision and team meetings. Staff demonstrated a clear understanding of the service’s values, culture and expectations and told us they felt equally treated.

People’s views were sought through weekly residents’ meetings, key-worker sessions and surveys. People told us they could approach the registered manager or staff if they had a concern. Observations showed positive and responsive interactions between managers, staff and people.

Leaders did not always fully understand the context in which the provider delivered care, treatment and support.

There were shortfalls in leaders’ oversight of some risks. Priority fire-safety actions identified in an earlier fire risk assessment had not been completed until the inspection, checks of window restrictors were not recorded, and required notifications concerning safeguarding and a police incident had not been submitted to CQC at the appropriate time. These concerns demonstrated that leadership oversight and risk management were not consistently effective.

However, the registered manager was visible and accessible. We observed the registered manager and staff speaking respectfully with people. Staff provided one-to-one engagement in private areas and gave people time when they wished to talk. Two senior support workers contributed to running the home, and staff had key-worker responsibilities and contributed to reviews of people’s care. Regular team meetings enabled staff to participate in discussions about the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People and staff spoke positively about the registered manager and felt able to raise concerns or suggestions at any time. Staff described the registered manager as “Very supportive” and “Always available.” Staff could also contact a member of the management team through the out-of-hours on-call arrangement. One person said they would approach the registered manager if they did not feel safe, while another told us, “I would speak with the registered manager or staff. If I have any problems. They listen to me.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider supported an inclusive workforce and promoted equality, diversity and inclusion. Policies and procedures were in place and staff had received training. The workforce included staff from a range of backgrounds and cultures. Although no flexible working arrangements were in place at the time of our inspection, staff overwhelmingly told us they felt the registered manager would be sympathetic to any request for this.

Staff received regular supervision sessions and training and were able to attend team meetings to discuss issues in relation to service provision. They spoke positively about the support they received from the registered manager.

The provider did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The provider's governance arrangements were ineffective and failed to identify, monitor and address significant risks. Fire safety concerns identified within an independent fire risk assessment had not been addressed for almost a year, despite being referenced during some quality assurance activity. The most recent quality assurance monitoring had not identified these concerns. Window restrictor checks were reportedly completed; however, no records were maintained, meaning leaders could not demonstrate effective oversight of environmental concerns which could potentially put people at risk.

The provider had also failed to submit statutory notifications to CQC, including notifications relating to a safeguarding concern and a police incident. One notification was only submitted following discussion during the inspection. Quality assurance processes were primarily focused on health and safety and were not sufficiently robust to identify shortfalls in governance systems, or monitoring processes. For example, reviews of care plans had not always been recorded and there was a failure to identify that key information about care and support needs had not always been integrated into people’s care plans. This meant people were potentially at risk in case of an emergency health or other crisis.

These concerns demonstrated a breach of legal regulations relating to good governance.

Incident and accident records did not always demonstrate learning or follow up actions.

Staff asked people for their views through weekly residents meeting and key worker sessions. However, the records of these did not always demonstrate that planned outcomes were achieved.

Staff nevertheless understood their individual responsibilities and told us they could access support from managers and senior support workers when required.

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.

The provider’s records showed engagement with mental health teams, social workers and other health professionals to support joined-up care. The registered manager and a senior support worker described their contact with these services as being positive. The registered manager also attended a local authority forum for care-home providers and told us these helped them learn about best practice and the work of other services.

Staff understood the value of these relationships. A staff member said, “We see mental health workers and social workers. Sometimes doctor or hospital. The professionals are very supportive and help people with things we can’t do.” A person confirmed that staff supported access to external healthcare, stating, “They remind me about the dentist and doctor and make appointments for me if I want.”

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always actively contribute to safe, effective practice.

The provider’s systems did not consistently identify shortfalls or ensure learning led to sustained improvement. Priority work relating to fire doors had remained outstanding until the inspection. Accident and incident records did not consistently show follow-up and outcomes. Information from incidents was shared through handovers and daily notes, but it was not always transferred into care plans and risk assessments. This meant learning was not always readily available to staff or embedded in people’s care records.

The service had previously been rated good, but the current assessment identified failures, particularly in relation to safe and Well-led. The provider responded to several concerns during the inspection. Fire-door guards and seals and a broken window restrictor were replaced, daily medicines counts were introduced, capacity assessments were completed, and emergency information was placed in a “grab and go” bag. These actions showed responsiveness, although they were largely taken after inspectors raised the concerns rather than through the provider’s own improvement systems.

The registered manager said they would act on the inspection feedback to support future improvement.