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 remained 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 provider was previously in breach of the legal regulation in relation to good governance. Improvements were found at this assessment and the provider was no longer in breach of this regulation.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

At our last assessment of this service we found the provider had failed to improve their governance and oversight processes since the last inspection.At this assessment, we found the provider had made improvements. However, further time was required to ensure improved practices were embedded and formed an on-going part of the providers governance, auditing and oversight processes.

The registered manager had made appropriate notifications to CQC and referrals to the local authority safeguarding team. However, the provider’s Statement of Purpose required updating with new information relating to the registration of the service and manager and an accompanying notification to CQC. The service was providing care to people living with dementia but had not sent a notification to CQC to add this service user group to its registration. We spoke with the registered manager about our findings at the time of the inspection who took immediate and appropriate action.

The registered manager had made improvements to the oversight, monitoring and management of service systems and processes. These included identifying and mitigating risk, improved accuracy and consistency of records, auditing checks to identify where improvements were required and a dynamic service improvement plan.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.