Ambleside

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 requires improvement. At this assessment the rating has changed to inadequate.

This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation people’s safe care and treatment.

This service scored 38 (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 have an effective system in place to evidence there were lessons learned, themes analysed or staff had completed reflective learning. There was a repeated lack of maintaining accurate and effective monitoring and recorded documentation around effective management of incidents. Previous inspections had raised similar areas of concern or required improvements which had not been embedded into the provider’s learning culture.

We saw an accident and incident monitoring audit document which was a simple tally chart of monthly events and not an effective audit record. The provider also used a variety of different forms to record events, which meant there were no standardised or consistent records with descriptions of the accidents and incidents, comments, actions taken or outcomes.

We reviewed a concerns log, which documented the concern and action but the outcome to determine if the concern had been resolved or not, was brief and lacked sufficient detail. For example, “Manager spoke to [person] and to staff”. This meant the registered manager could not be assured if the action taken had been effective. Some records had been added following our inspection and the sharing of our concerns with the provider.

The provider had a complaints policy and procedure and an accident and incident policy and procedure in place, both of which had been reviewed and updated prior to our inspection.

We spoke with 8 members of staff who all told us they knew what actions to take, how and when to add to the accident and incident log. They told us learning meetings or training sessions were held following an event.

The provider did not always work with people and partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

We reviewed information regarding when a person had transferred from the service to another care home. Safeguarding concerns had been raised by the new provider. Whilst Ambleside had correctly raised their own concerns about the persons physical needs to the GP and Community Nurse, prior to the transfer; incomplete information about the person had been shared with the new care home. The person’s care records and risk assessments had not been updated following a change in their needs whilst living at Ambleside.

The provider had recently reviewed a handover process with staff to relay information between each shift to more accurately share and report information about people and the service. We found the provider had addressed this shortfall as staff meeting minutes stated, ‘communication at Ambleside could be much better’. The people and families we spoke with expressed no concerns with the transfer of care into the service.

People had an initial assessment derived from a local authority referral and support plan, a hospital transfer into Ambleside and respite care. The provider then developed a personalised care plan to include people’s primary care needs, and relevant assessments.

The provider had not always concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The provider’s log had only documented one safeguarding incident in 2025 but we were aware of 3 other safeguarding concerns which should have been recorded on the log and the provider had failed to legally notify CQC of these incidents. The providers audit had also failed to identify this shortfall. This meant people were at risk of receiving unsafe care as the provider had not been open and transparent.

The provider had a safeguarding policy and process in place which had been reviewed and updated prior to our inspection. The provider had a Deprivation of Liberty Safeguards (DoLS) tracker in place to identify who had authorised legal restrictions to their liberty, in place.

The people and families we spoke with all told us they felt safe living at Ambleside. One person said, “I know that we are secure, that people cannot walk in here, we don’t get any unexpected guests, they shut my door at night but don’t lock it, which is just what I want.”

Comments from family members included, “Yes, we consider that he is safe, he always is. I have seen no issues that cause any concern” and “I think he is safe. I think they look after him well.”

A visiting professional told us, “[The provider] is sharing the right concerns, in particular around skin tears and falls.”

All the staff we spoke with were confident they knew how to recognise signs of abuse, when to act and who to report their concerns to. One staff member told us, “If I suspected mistreatment, I would first make sure the person is safe, report it immediately to my senior, record the facts clearly, and follow my organisation’s safeguarding policy. I would never ignore a concern, and I would maintain confidentiality while making sure the individual feels supported.”

The provider did not always work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

One person told us they would like to be able to access the garden independently and was not able to do this due to a step outside their garden access door. There was no positive risk-taking assessment or recorded plans to facilitate this requested need.

On the first day of our inspection, we reviewed people’s personal emergency evacuation plans (PEEP’s). There was no record of people’s PEEPs held in the service; however, we were told these were being updated off site. PEEP’s prioritise the safety of all people especially those who may not be able to evacuate independently. These were in situ on the second day of our inspection.

People were exposed to risks because the provider did not always operate an effective system or process to record, recognise or act on risks. This included risks around medicines administration and environmental risks. People were put at risk of harm as the home’s environment had not been maintained.

Some care records were not accurate or contemporaneous. One person’s record stated the outcome of a multidisciplinary team meeting (MDT) where the dietician had requested fortified meals in small quantities in between meals, however, we saw no recorded evidence of this being provided. The dietician stated this person did not like particular food types, but service records showed this meal was being provided regularly.

We reviewed 4 people’s care plans and risk assessments. Individual risk assessments such as using a four wheeled walker, or showering detailed the identified hazard, the control measure and the likelihood and severity of the risk.

Staff told us they were confident about how to mitigate the risks people faced. One staff member told us, “[Care plans and risk assessments show] the individual needs, their known risks and the safe way to support them. They tell us what to look out for and how to prevent accidents, it is updated if there are any changes.” Another staff member said, “[Risk assessments] tell me their triggers, their support needs, and the actions I must take to keep them safe. They tell me what equipment to use, how many staff are needed, and how to respond to emergencies. I feel I have enough information to manage risk.”

The provider did not operate effective systems to monitor the safety and upkeep of the premises, placing people at risk.

The kitchen fridge and freezer temperatures had been routinely recorded but 16 out of 44 entries had been recorded outside of the range with no clear records that actions had been taken. Maintaining required refrigeration temperatures is crucial for food safety and business compliance. It is a legal requirement for food businesses to store food at temperatures that do not pose a risk to health. This includes storing high-risk foods at or below 5°C and ensuring that refrigerators and freezers operate within the required temperature ranges. Regularly checking and recording fridge and freezer temperatures helps ensure that food is stored safely and complies with food safety regulations.Following our inspection and the sharing of our concerns with the provider, a memo was distributed to staff to check, report and record when temperatures were out of range and a kitchen action plan.

Hot water temperature check records did not identify a safe range. Following our inspection and the sharing of our concerns with the provider, the documentation had been updated and included the safe range to prevent scalding, and checks had been completed in November.

People were put at risk of harm as the home’s environment had not been maintained. We observed a broken air vent which was sharp in one person’s room and a lack of intensive cleaning generally in people’s rooms and bathrooms. There was a cracked and broken windowpane which had a large hole in the communal area near to seated people. As a result of sharing our concerns with the provider the window was replaced on the second day of our inspection.

We reviewed the external provider’s fire risk assessment and an external provider’s health and safety assessment in relation to asbestos management. The fire risk assessment action plan had not been completed. The required works for asbestos safety had gaps on the action plan which stated an agreed timescale of 6 weeks from February 2025. The manager told us the actions had been completed but we did not see a record of this at the time of the inspection.

Care homes must act in accordance with fire safety reforms (The Fire Safety (England) Regulations 2022) to protect the safety and well-being of their residents. Legislation is designed to prevent fire incidents, ensure early detection, and provide safe evacuation routes. It also ensures that care homes are equipped to respond effectively to fire emergencies, reducing the risk of fatalities or serious injuries.

The provider had not maintained robust systems to check a fire alarm test record which had been completed weekly until mid-September and the fire procedure was last completed October 2023. The fire drill for the service was last completed in April and again in October 2025, following our inspection. Fire Marshall training was completed, and appliance testing was arranged by the manager following our inspection and the sharing of our concerns with the provider.

The provider shared an updated Service Improvement Plan. While some of the necessary fire and asbestos safety actions were completed in March, April, and August 2025, the rest were addressed only after our inspection raised concerns. We also shared our concerns with the local Fire Authority as these concerns placed people at risk of being harmed by their environment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs. Improvement was required in the safe recruitment of staff.

We reviewed the previous 4 weeks staffing rotas. The service used a minimum of 3 staff but did not use a dependency tool. A dependency tool provides a structured method to assess the care needs of people, which is essential for ensuring the right number of staff with the right skills are available at the right time. Without these tools, care homes may rely on outdated methods or guesswork, leading to potential staffing shortfalls and compromised care quality. Dependency tools also help in planning staffing levels to maintain the quality of care and support, which is crucial for the well-being of people.

We had mixed feedback from staff members regarding staffing levels. One staff said, “Staffing levels are always adequate, shifts are covered, and we work well as a team to support each other, we always have a lot of staff on duty.” Another told us, “Staffing levels are generally adequate, but sometimes there may not be enough staff due to sickness or unexpected absence. We had mixed feedback regarding staffing levels from people and their relatives. One person told us, “I do think they need a couple more staff, sometimes you have to hunt for someone if you do need something.” A family member said, “I think the staff numbers appear to be about right”. The manager told us they would add in an extra member of staff if anyone required one to one care and they would consider using a dependency tool in the future.

We reviewed staff recruitment records and found these were disorganised with some records missing. For example, we found a lack of one-to-one supervision records; limited identification records and gaps of employment records. The provider had a schedule for staff appraisal and supervision and staff told us they received regular support. However, we saw gaps in staff supervision records.

We reviewed staff training records and found staff received on-line and face-to-face training. The training records and competency assessments were a simple tally of what had been completed by which member of staff. There were several different documents used, and it was difficult to ascertain if there were any gaps or overdue training as the provider had not maintained an effective system to monitor staff development and support. For example, we found equality and diversity training was not part of the providers training record and not all staff had completed the same areas of training. One professional who had delivered face to face training told us, they did not feel all training was cascaded well enough and ‘most staff don’t appear to know what they are doing.’ However, staff we spoke with said they received very good training.

Staff told us they received a suitable induction to the service. One staff member told us, “I received both theoretical and practical induction. I was given time to read the policies and procedures. I was shown how to carry out tasks safely and shadowed experienced staff. It was very helpful and prepared me for the job.”

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The provider did not operate effective systems to monitor the cleanliness of the home and storage of food items, placing people at risk.

We found the kitchen was not clean. The kitchen floor was stained, the workbench legs, sides of the fridge and cooker were stained with drips and crumbs. The floor, pipes and the tiles at the back of the workbench were not clean, the gaps in between floor standing appliances and cupboards were not clean. Following our inspection and the sharing of our concerns the provider shared a daily kitchen cleaning schedule for night staff and a plan to replace the flooring. We requested a follow up visit from an external stakeholder partner. The service had been scored a Food Hygiene Rating of 4 and following a recent review this had changed to 3. The partner shared concerns with us about a lack of consistent and sustained improvements following their inspections.

The storage of kitchen items was cluttered and mixed. During the inspection, we identified vegetables being stored loosely in a basket on the floor. Items of food had not been labelled or closed securely. Following our inspection and the sharing of our concerns with the provider, the manager distributed a memo to remind staff to store food correctly.

These infection control concerns placed people at risk of spread of infection.

We reviewed infection prevention and control audits, and although the manager told us these had been reviewed annually, there had been no action taken since 2017. Following our inspection and the sharing of our concerns the provider completed an up-to-date infection prevention and control and a personal protective equipment audit. However further time was needed to embed and monitor these improved infection control practices.

Staff we spoke with knew how and when to use personal protective equipment and dispose of it safely.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

At our last assessment of this service, we found the provider was in breach of the legal regulation in relation to people’s medicines. At this assessment, we found sufficient improvements had not been made and the provider remained in breach of this regulation.

We found there was a continued failure to ensure medicines were consistently recorded and administered accurately and safely.

We reviewed a daily medication monitoring document which identified gaps in the medicine administration records (MARs) on 3 separate days without any actions recorded. This meant we could not identify whether people had received their medicines or not.

We reviewed 4 out of 15 medicine records and found medicines were not always managed safely. Medicines had not always been recorded and administered appropriately or in line with the provider’s medication policy and procedure. Following our inspection and the sharing of our concerns with the provider, memo's were sent to staff to remind them of the providers medication policy and procedure, to ensure people received their medicines safely and as prescribed.

For example, one person was prescribed an inhaler, and the Medicines Administration Records (MAR’s) showed it had been refused for 17 days. There was no record or evidence to demonstrate what actions had been taken, such as a discussion with the GP. The omission of this medicine could have negatively impacted the person’s health condition.

Two people’s care plans stated there was a support plan in place for a blood thinning medicine, however this was not present in their care records or medicines folder. These records are important to mitigate any risk of bleeding or bruising associated with this type of medicine and to guide staff on how to monitor the person effectively and safely.

Another person was prescribed a cream. There was no entry on the person’s MAR to evidence these prescribed creams had been administered. There was no corresponding body chart to identify where the cream should be applied. The provider told us the entry had been made on a separate chart; however, this did not form part of the MAR. The administration of medicines should be recorded on people’s individual MAR. This record is essential to evidence people are receiving the right medicines at the right time and helps in monitoring and reporting any issues related to medicine administration. The MAR chart also serves as a reference point to double-check dosages, timings, and any additional instructions, ensuring that people’s safety and medication management are prioritised.

Another person had a schedule 5 controlled drug prescribed for pain relief. There was no record or protocol to detail why this medicine had been administered as a ‘when required’ (PRN) medicine. There were handwritten notes on the back of the MAR which showed this PRN medicine had been administered at the same time on 6 consecutive dates, which indicated it was scheduled and not ‘as required’. This could increase the risk around inappropriate administration. One PRN protocol for the use of an inhaler was not linked to the person’s MAR.

Another person’s record had an inaccurate record of 3 different medicines. The MAR recording had stopped part way through the month and re-started on a different MAR, the dates did not match. This could lead to medicines being omitted or duplicated. One prescribed topical cream had been opened and used but did not appear on any MAR chart. The MARs did not have a reliable divider between each person to minimise the risk of potential errors in administration. We reviewed a daily medication monitoring document which identified gaps in the MARs on 3 separate days without any actions recorded.

However, other MAR’s reviewed had been recorded accurately, including a running balance sheet. Some PRN protocols were in place, and some PRN records showed where a GP had reviewed the medicines. We reviewed one person’s document for the safe administration of covert medicine and found the correct protocol was in place. Following our inspection and the sharing of concerns found, the provider reviewed and updated the care plan, risk assessment and mental capacity assessment relating to this person’s covert medicine administration. The provider also distributed a memo reminding staff to make accurate recordings on the MARs.

When areas requiring improvement were identified the manager implemented a medicines error incident report and staff supervision report. However further time was needed to embed and monitor the improved medicines management practices.

We found the provider had not made sufficient improvements to their medicines management processes since our last inspection. As a result, a warning notice has been issued as the registered person has failed to improve their medicines processes and comply with the regulation 12.