Ambleside

Ambleside is a residential care home providing accommodation and personal care to up to 18 people. The service provides support to older people, some of whom live with dementia. At the time of our inspection there were 16 people using the service. People were accommodated in one adapted building across 3 floors.

People’s experience of using this service and what we found

People’s medicines were not always managed safely. This included unsafe administration practices and a lack of clear guidance for staff on the use and administration of some medicines.

The provider was making improvements to their fire safety arrangements following recommendations made by the local authority fire safety team. However, people’s personal emergency evacuation plans (PEEPs) required up-to-date information about what support people required in the event of a fire.

Staff were aware of the risks which could potentially impact on people’s health and safety and knew what action to take to reduce harm to people. However, relevant records did not always accurately reflect people’s risks and the actions needed to keep them safe. Risks were not always suitably assessed or reassessed when people's needs or circumstances changed, to ensure appropriate and suitable risk mitigation actions were in place.

The provider's systems for monitoring the quality and safety of the service had not been effective in identifying and addressing the shortfalls identified in this inspection.

Relevant information was shared with external agencies, including health and social care professionals and the local authority, when incidents occurred, or when people’s health altered, so they could review or reassess people’s needs as required.

Both managers and staff told us they felt comfortable with the numbers of staff deployed to care for people. Additional staff were employed to clean, cook, and support people with social activities. Staff were recruited safely.

Regular safety checks including, maintenance and servicing took place to ensure all systems, utilities and equipment remained safe.

The senior management team shared responsibilities and management tasks when managing the service. They were clear about the areas they were responsible for, and the staff were clear about which manager to report concerns and issues to. The registered manager and provider were kept well informed of all incidents, accidents and events which took place in the care home.

The registered manager worked regularly with staff to provide support, review their practices and competencies and to monitor workplace culture. They attended staff handover meetings and held regular staff meetings to keep staff informed and to gain feedback. Feedback was also sought from people who used the service and actions taken in response to the feedback.

Staff and people’s relatives told us they found the senior management team to be approachable, supportive and inclusive.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 8 August 2022).

Previous recommendations

At our last inspection we recommended the provider consider how they recorded actions for improvement along with the completion of those actions. At this inspection we found actions for improvement were recorded but there was not always a record of whether these actions had been completed.

Why we inspected

The inspection was prompted in part by notification to CQC about an incident following which a person using the service sustained serious injuries and died. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. The incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of that incident.

For those key questions not inspected, we used the ratings awarded at the last inspection in which those were inspected to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ambleside on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to the management of medicines, review and reassessment of risks and the provider’s monitoring processes. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Ambleside is a residential care home providing personal and nursing care to up to 18 people. The service provides support to older people, some who live with dementia. At the time of our inspection there were 13 people using the service.

People are accommodated in one adapted building and have access to outside spaces with support.

People’s experience of using this service and what we found

Improvements had been made to how managers assessed the effectiveness of their quality monitoring processes. There were now systems and processes in place for managers to effectively identify any shortfalls and address these. The improvements supported managers to stay aware of ongoing changes in the service, for example, changes in risks, people’s health and infection, prevention and control guidance and to make necessary adjustments to procedure or practice as required.

We have made a recommendation in relation to how actions for improvement are recorded.

The management of risks had improved which was improving people’s safety. Records providing staff with guidance on how to manage people’s health and infection risks had been reviewed. Amendments had been made where required to ensure guidance about these was up to date and matched people’s requirements.

The process for monitoring the effectiveness of the service’s risks management, along with staffs’ related practices, had also improved. Managers had systems in place which helped them be sure that the adopted and implemented risk management actions remained effective in reducing risks to people.

The management had been open and transparent about how they had managed concerns received by them and the information they had shared with external agencies and professionals in relation to these.

These improvements now needed to be sustained.

Whilst arrangements were being made to replace the old call bell system, people had been provided with an alternative way of contacting staff when they needed their support.

One person told us they had stayed in other care homes but were happiest at Ambleside stating staff tried hard to keep them happy and they would recommend the home. Another person appreciated being able to have a cup of tea and biscuits when they asked for them. People had mixed views of the food provided and social activity opportunities. The provider had sought people’s feedback earlier in 2022 and had followed up people’s feedback at the time.

The environment was clean and there were no restrictions on visiting. Feedback from one visitor was positive about the care provided to their relative and the support given to them by the staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 11 April 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced focused inspection of this service on 3 and 4 March 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment. The provider was also required to make improvements to the governance and monitoring of the service by 20 May 2022.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ambleside on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Ambleside is a residential care home providing accommodation for persons who require nursing or personal care to up to 18 people. The service provides support to older people; some of whom live with dementia. At the time of our inspection there were xx people using the service. People are accommodated in one adapted building across two floors.

This was a focused inspection that considered infection, prevention and control arrangements, people’s care, treatment and support and the leadership, management and governance arrangements.

People’s experience of using this service and what we found

Shortfalls in infection, prevention and control practice, including those found in people’s care records, had not been identified by the provider. Arrangements in place had not ensured safe practice guidance had been followed and that where needed, improvements were made. People had been at risk of receiving unsafe care and treatment due to a lack of senior leadership and effective quality monitoring processes.

At the time of the inspection we found care staff had ensured people’s care, treatment and support needs were met. Staff were appropriately referring people to relevant healthcare professionals. One relative said, “Yes, the doctor comes around routinely to check.” Another relative said, “(Name of relative) was malnourished when they came here. They encourage (name of relative) to eat.” The relative said their relative had benefited from this. A visiting healthcare professional told us relevant health reviews took place and that care staff were aware of people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 15 November 2019).

Why we inspected

We received concerns in relation to people’s care, treatment and support and in relation to the management of the service. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this full report.

During the inspection action was taken by a representative of the provider to better protect people from COVID 19 infection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ambleside on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to how risks to people are reduced and mitigated and, in the management and monitoring of the service’s processes and practices.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Ambleside is a residential care home providing personal care to people aged 65 and over, some of who live with dementia. Ambleside can accommodate 18 people in one adapted building. At the time of the inspection 16 people lived there.

People's experience of using this service and what we found

Improvements had been seen across the service since our last inspection. The registered manager worked alongside the management team to continue to embed new ways of working and there were plans in place for the service to continue to develop. A number of new systems to monitor and improve people's experience of receiving care had been introduced however, they were in their infancy and required further development and time to become fully effective.

People told us they felt safe living at Ambleside. The management team were focused on making improvements and involving people. Staff worked regularly and closely with other stakeholders to ensure a safe and effective service was delivered.

People were protected from the risk of infection as appropriate measures had been taken. Risk management tools were used to identify and manage risks to people. There was a pleasant atmosphere in the home, where people's privacy and independence was respected.

People received individualised care from safely recruited staff that were trained, supported and knowledgeable. People's needs were assessed on a regular basis and care adapted to meet any changing needs. People received their medicines as prescribed and their health and nutritional needs were met.

The provider worked with healthcare professionals to provide effective care to people and people had access to professionals such as a GP. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People's care was reviewed on a regular basis which helped to ensure their needs were met. There was a program of activities within the home and provision for activities in the community had improved.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 6 November 2018) and there were three breaches of regulation. The provider had failed to operate effective quality monitoring systems. The provider had failed to effectively manage risks in relation to the environment and people’s health and safety. The provider had failed to plan care and treatment to meet people's needs and preferences. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

Ambleside is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home specialised in the care of people who lived with dementia. It also provided a day care service.

Ambleside can accommodate 18 people in one adapted building. At the time of the inspection 15 people lived there. People were provided with single bedrooms with en-suite toilets and washing facilities. The home had two communal bathrooms; only one had been adapted to support assisted bathing. There was a dining room, front lounge and conservatory at the back. A passenger lift supported access to the upper floors and there was assisted wheelchair access to the building. Parking was available at the front of the building.

There was a registered manager in position. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection on 19 and 22 May 2017 we rated the service ‘Requires Improvement’. People’s care records had not always been maintained accurately in order to reflect their planned care, the care they received and decisions made on their behalf. Improvements were also needed to the provider’s quality monitoring processes as these had not identified the above shortfalls. We asked the provider to complete an action plan.

During this inspection we found some improvements had been made but further improvements were needed and we again rated the service ‘Requires Improvement’ overall. This is the second time the service has been rated ‘Requires Improvement’.

We found improvements had been made to people’s care plans making them more detailed. However, we found shortfalls in other records, relating to people’s care and the management of the service. For example, care monitoring records, accident and incident records and those used for quality monitoring purposes.

We also identified a lack of cleanliness, poor cleaning arrangements and poor maintenance of the premises. Quality monitoring systems were not effective. They had not sufficiently identified areas which required improvement. For example, relating to risks associated with ill-fitting floor coverings, general maintenance and a lack of cleanliness. The audits and checks used in this process had not always provided the registered provider with the correct information to identify where improvements were needed.

Where concerns were known to the registered manager, prompt and effective action had not been taken to ensure risks were managed and improvements made and sustained. In some areas the registered manager relied on other staffs’ information and verbal feedback, regarding areas for improvement. They did not always have their own processes in place for following these up or carrying out their own checks.

A system for demonstrating that progress was being made on required actions and that on-going improvement was planned, was not in place. For example, actions for improvement did not then form a central improvement plan which could be worked on and collectively reviewed by the managers. However, a newly formed service improvement plan was sent to us following this inspection, showing us how and by when some areas for improvement were to be completed

People received support to take their medicines, but by not recording the specific time people were administered pain relief, put people at potential risk of medicine errors. We have made a recommendation about the recording of time-sensitive medicines.

Although some recruitment checks were carried out prior to staff starting work, these had not always been as robust as they could have been. We have made a recommendation about staff recruitment checks.

People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible. However, where people who had not provided consent to live at Ambleside, and where people were not free to leave the home independently, there was no evidence to show that full processes under the Mental Capacity Act 2005 had taken place. We have made a recommendation about seeking current best practice in relation to the MCA and DoLS to ensure necessary regulations are met.

During the inspection we observed limited opportunities for people to take part in social and meaningful activities. There was evidence to suggest this had not always been the case however, and a new activities co-ordinator was due to start soon.

There was a lack of support to help people who lived with dementia to remain orientated to time, day, month and season. People did not always receive the care they needed to maintain their personal hygiene.

People’s nutritional risks were addressed and people had a choice in what they ate and drank.

People had access to health care professionals when needed.

Staff had received training and support to carry out their roles. People and their visitors told us staff were caring, kind and respectful. People’s relatives, and their representatives, where appropriate, could visit at any time and be actively involved in planning and reviewing people’s care.

People’s privacy and dignity was maintained. Staff knew the people they cared for well and could communicate with them effectively. People were supported to have a comfortable and dignified end of life. People’s care plans gave staff guidance on how to meet their needs. These had been improved to contain more personalised information. They were reviewed and kept up to date.

People and visitors to the home could make a complaint or raise areas of dissatisfaction. Lessons had been learnt from concerns which had been raised and the home had been transparent in its investigations about these.

The views of relatives and other visitors to the home had been sought earlier in 2018 and questionnaires contained predominantly positive feedback about the service.

Three breaches against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified during this inspection.

You can see what action we told the provider to take at the back of the full version of the report.

A registered manager was in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People and their relatives were positive about the care they received. We observed the relationships between staff and people receiving support demonstrated dignity and respect at all times. Staff knew, understood and responded to each person’s needs in a caring and compassionate way. Staff had the knowledge and confidence to identify safeguarding concerns and told us they would act on these concerns to keep people safe.

People told us there were enough staff to meet their needs. Staff rotas confirmed this. Staff carried out additional duties when required. The registered manager frequently worked as part of the care team. Recruitment checks had been carried out to ensure staff were suitable to work with people. Staff told us they were supported well and had the training and skills they needed to meet people's needs.

Staff had responded quickly when incidents had occurred or people’s needs had changed. However, people’s care records were not consistently amended to reflect their support needs, changes in their well-being, consent to their care or the management of their risks. The registered manager had responded to relative’s comments about the lack of activities provided for people and was working towards providing a greater range of activities tailored to people’s needs..

The registered manager and the provider’s representatives responded to people concerns and monitored the quality of the care provided, although shortfalls in people’s care planning had not been consistently identified during their auditing process.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we told the provider to take at the back of the full version of this report.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This inspection was completed by one inspector. We visited the home and spoke with people who lived in the home. This is a summary of what we found based on our observations; speaking with three people who used the service and families; talking to staff and looking at records.

'Is the service safe?

We saw people being treated with dignity and care. People told us they felt safe at the home and they liked the staff. We saw people being supported and cared for in line with their care plans. We inspected people's care plans and saw that assessments had been put in place to observe and document changes in people's health and well-being. People were consulted about the day to day running of the home such as activities. The safety of people in the home had been assessed. For example the registered manager told us that a fire officer recently inspected the home. We saw emergency fire evacuation plans in the care plans that we inspected. The registered manager told us that no application to register a person under the Deprivation of Liberty Safeguards had been made and no one in the home was deprived of their liberty without good reason.

'Is the service effective?

People were given nutritious food and drinks which were available throughout the day. People told us they enjoyed the food. We inspected documents that told us the people's physical and mental health needs had been identified and were being met. People had been referred to other health care professionals when needed. The care plans focused on individual care needs and gave staff clear guidance of the support people needed. The care and support of people who lived in the home were reviewed monthly and any changes were recorded in the care plans.

'Is the service caring?

Staff spoke with people in an appropriate and respectful manner. People told us they liked the staff and that they were caring. We saw staff providing choices and options for people. Staff recognised when people became upset or agitated and supported them in a timely and appropriate way. We saw staff encouraging people to be independent in their daily activities such as eating.

'Is the service responsive?

People told us they were able to raise concerns with the registered manager or operational manager of the home. Staff provided opportunities for the people who lived in the home to feedback concerns or issues, for example in meetings or post comments in a suggestion box. Staff had responded to suggestions about activities and the d'cor of people's bedrooms. We read that staff had managed and responded to recent medical emergencies. Staff had engaged with health care professionals to provide additional advice or support for individual people and implemented any changes.

'Is the service well led?

The registered manager and senior care staff had undertaken leadership training. The registered manager had effective systems in place to monitor the staff's competency and skill levels to carry out their role. Staff told us they felt supported and well trained. Various arrangements had been implemented to monitor the risks to people's health and wellbeing. The registered manager responded to and investigated complaints. Staff were encouraged to learn and improve the care and practices provided from the complaints made. This helped to prevent issues occurring again.

The purpose of this inspection was to follow up on the four areas of concern we found at the inspection on 23 April 2013. The provider sent us an action plan following this stating how they would become compliant. The areas of concern were; people were not involved in the running of the service or in their care and treatment, lack of activities and stimulation for people, unsafe system for the management of people's monies and lack of on-going maintenance of the environment.

We found evidence that people were now involved in their care and treatment where able. Meetings with people were taking place and their views were listen to and acted upon. People had access to activities and outings.

A safe system was now in place for managing people's monies.

Re-decoration had taken place to parts of the environment and changes had also been made to help people with their daily activities.

A new manager had recently started at the home and they told us about some of the plans they had in place to improve the service for people.

We found that people were looked after well. But as the needs of people had increased this had meant there was less time for staff to spend with people socialising and interacting with them. This had resulted in people not having any stimulation or activities other than the outside entertainers.

We found that improvements were needed with the environment and the provider told us they had plans in place to address this.

Staff told us they enjoyed working at the home, but it had got very busy as the needs of people had increased.

As part of this inspection we followed up on the compliance actions we issued following the inspections in January 2012. We found at these inspections that people were not having their needs met and we identified a number of serious concerns.

Following this the provider appointed a new manager and they have since been registered with us.

At this inspection we found the home was now compliant and the outcomes for people had vastly improved. Staff said they felt the standard of care had improved over the last few months and they felt better supported by the registered manager. One person told us that since the new cooks were appointed they can have the same as other people as they required a specialist diet. They said "the dumplings are excellent".