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.This is the first assessment for this newly registered-service. This key question has been rated 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.

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.

People were not confident their feedback was listened to and acted upon to improve things. One person said, “At the last relatives meeting there were only four there. They are a waste of time; they don’t action anything. I haven’t seen the minutes for the last meeting yet.” Another person said, “I’ve just said they need more staff, but a manager showed me an email from head office saying there’s enough staff. Whenever I ask for something to be done, it rarely happens.” The provider had systems and checks to review accidents, incidents and people’s care to ensure it remained accurate. A senior member of staff explained the process and procedure for recording accidents and incidents. This included completing an accident and incident form, implementing monitoring charts and reviewing people’s risk assessments and care plans. Staff told us learning or changes in response to accidents and incidents was shared during the handover of information between shifts. One staff member explained, “Learning is mostly through handover, so if there is a change in process, the unit leaders will tell us in handover." However, we found some people’s care information was inconsistent, not updated or it was not recorded accurately. This meant we could not be confident learning was always shared through staff knowledge and the provider’s own analysis.

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. Staff confirmed if a person was admitted to hospital, they would send the person’s medicines administration record and their RESPECT (Recommended Summary Plan for Emergency Care and Treatment) form. However, a senior staff member confirmed they did not routinely send information about people’s individual risks or preferences such as a hospital passport or summary of people’s key risks or general care needs. This meant important information about people might be missed in the transfer between services. When people were discharged back to Ambleside after a hospital stay, any changes were reviewed and recorded on the electronic care planning system.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from harassment, abuse and neglect. People felt safe at Ambleside. One person said, “I do feel safe as staff walk around all the time, they are very observant. I’m very happy here, I’d speak to the senior nurse if there was a problem.“ Staff told us they were confident to escalate any concerns about people’s health and wellbeing and poor practice by their colleagues. A typical staff comment was, “I would always listen to people and hear them out and if anything needed reporting, I would do it. Nobody should get away with it, even if you are the manager or the top boss."

The provider did not work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Overall, risk management plans contained information to inform staff how to reduce people’s identified risks. However, we found most of the care plans we reviewed had discrepancies and inaccuracies in risk assessment tools and risk management plans. For example, 1 person had been assessed as high risk of malnutrition in February 2025. The risk had been calculated as low in March 2025 despite the person continuing to lose weight. This person had been assessed as very high risk of skin damage. Their night care plan stated they needed to be repositioned every 2 hours during the day and 4 hourly at night to reduce the risks. When we requested the repositioning records, a senior member of staff told us the person was not repositioned, and the care plan was inaccurate. Another person had been assessed as high risk of choking, but it was not clear what information had led to this risk rating. We checked another person whose skin integrity was at risk. They had a specialist mattress to ease pressure areas on skin and required repositioning. Staff, care records and repositioning charts were all inconsistent as to how often the person needed to be repositioned. In a number of cases, agreed times to reposition were not followed. Some staff told us to alleviate pressure they used a cushion or a pillow to support the person, but we were not confident this was effective because staff and managers gave us conflicting information. This meant inconsistencies in risk management strategies put people at potential risk of harm.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. The environment was in good order and some communal areas were being refurbished to provide a welcoming and encouraging environment for people. Some adaptations had been made to keep people safe. For example, handrails in corridors had tactile studs to inform visually impaired people the handrail was coming to an end. A staff member told us any maintenance issues they reported were quickly addressed. Outdoor garden areas had been improved and people with mobility issues or people using wheelchairs, could access pagoda covered areas so they could be other people. Regular health and safety and fire risks were checked to keep the environment safe.

The provider did not make sure there were enough qualified, skilled and experienced staff. The majority of people and relatives told us staff were attentive when they were with them, but staff did not always respond to their requests for assistance promptly. Comments included, “When I ring my bell they always come quickly but at night it can be half an hour”, “They do rush you to eat at 5.00pm, I think it’s when the shift changes” and “This morning they didn’t get me up until 10.30am. It was because there aren’t enough of them, it happens a lot.” One person described how staffing affected them, saying, “I do feel they are short staffed, things take so long, A week ago, they didn’t have enough staff to give me a shower. I struggled to do it myself; it was dangerous.” During our assessment we saw staff were generally available and responsive when people required assistance or support. However, we identified there were times during the day when staff were very busy and found it more challenging to maintain oversight of communal areas. Overall, staff felt staffing levels were a challenge to respond promptly on the residential units. Comments included, "There should be 2 carers and a senior in the morning but there have been times it was just a senior and a carer." 'Following our visit, the provider confirmed if on occasions a staff member did not attend their shift at short notice, for example sickness, then the manager and deputy manager would support staff to keep levels at the assessed requirement. The provider used a tool to assess people’s dependency to identify safe staff levels and used additional hours to support each shift where required. The provider also reviewed call bell response times to ensure staffing levels remained responsive.' We discussed with management how they may wish toinform people and relatives of those staff on duty.Staff told us they completed regular training. One staff member told us, “We have dementia training, and they have brought in new positive behaviour support training so when the residents get a bit distressed, it trains you on how to deal with it."

The provider assessed and managed the risk of infection. The home was clean and tidy with no unpleasant odours and staff followed good infection control and food hygiene practices. The provider had processes to share information about any infectious outbreaks in the home to mitigate the risks of the infection spreading. Our observations showed staff wore personal protective equipment at the right times and they had enough supplies of stocks to keep them, and people protected.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff signed to say they administered people’s medicines according to their prescriptions. There was sufficient guidance contained in people’s records for staff about different types of medicines. Medicines were stored securely and according to guidance. One person was prescribed a medication to be given on an ‘as required’ (PRN) basis at times of anxiety or distress. The PRN protocol recorded that the medicine should be given for agitation and aggression. It did not contain any further information about the circumstances in which the medicine should be given to ensure consistency in administration and that it was only given as a last resort. The person did have a ‘behaviours of concern’ care plan which contained more detailed information about how to support the person at times of distress which mitigated the risk. However, good practice is to keep these guidelines with the medicines administration records. We also found similar examples for people who received medicines for pain management but there was limited information in people’s care records to support this.