This inspection took place on 10 and 11 September 2018 and was unannounced.

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 ca

This inspection took place on 19 and 22 May 2017 and was unannounced. Ambleside provides accommodation for 18 older people who require personal care without nursing. 16 people were living in the home at the time of our inspection. Ambleside is a small care home set over three floors. The home has two lounges, a dining room and a secure back garden. This service was last inspected in September 2015 when it met all the legal requirements associated with the Health and Social Care Act 2008.

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.

This inspection took place on 2 September 2015 and was unannounced. Ambleside provides accommodation for up to 18 people who require residential and personal care. 13 people were living in the home at the time of our inspection. Most of the people living in the home have been diagnosed with a type of dementia. Ambleside is set over three floors. The home has two lounges, a dining room and a secure back garden. This service was last inspected in May 2014 when it met all the legal requirements associated with the Health and Social Care Act 2008.

A registered manager was in place as required by their conditions of registration. 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’s care and support needs had been individually assessed and managed. Their records described people’s likes and dislikes and how they would like to be supported with their practical and personal needs. Staff were very knowledgeable about people’s needs, their backgrounds and their preferences. However their care records did not always consistently record their emotional or recreational needs. People were encouraged to make their own day to day decisions about their care and support. Where they had been identified as not having the capacity make a decision independently, this was not always recorded adequately. Systems were in place to ensure people received their prescribed medicines in a timely manner.

People and relatives were positive about the staff who cared for them. They told us the staff were kind and caring. People and staff had a friendly relationship. Relatives told us the home was homely and staff were compassionate. Their concerns and complaints were encouraged, explored and responded to in good time. Concerns and complaints were used as an opportunity for learning or improvement.

A range of activities were provided for people however not everybody had the opportunity to carry out individual activities which were important to them. People enjoyed the meals being provided. Staff monitored people who were at risk of losing weight. Where people’s needs had changed, staff made referrals to the appropriate health care services for additional advice and support.

Staff were knowledgeable about ensuring people were protected from risks and harm. They were able to tell us their actions if they felt people were being abused and harmed in anyway. Staff’s previous employment and criminal histories had been checked to ensure they were safe to look at after people.

There were sufficient numbers of staff to ensure people’s individual needs were being met. Staff had been trained and supported to care for people in an effective and responsive way. The registered manager ran the home well and understood people’s needs. They provided staff with support and had systems to monitor the quality of service being provided.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

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 décor 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.

We were not able to speak with all people who used the service because some people had complex needs which meant they were not always able to tell us their experiences. There were 12 people using the service during our inspection. We spoke with five people and observed staff interacting with people. The five people told us they were all very happy at the service and they told us they had no complaints. We observed activities taking place in the morning with some people. All people we spoke with complimented the food and one person said "we always have good food here".

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.

Not all people who used the service were able to tell us about their experiences because of their complex needs. We spoke to eight people, two relatives and four members of staff. All people we spoke with told us they were happy at the home and had no complaints. One person said "I am very happy here". We saw four quality assurance questionnaires that the service had sent to people and their relatives/representatives. Some of the comments from these included "care is very good and staff wonderful", "staff professional and caring". The two relatives said they had no concerns about the care but felt the staff should update them with the condition of their relative without them having to ask.

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.

All people we spoke with said they were happy with the standard of care they received. One person said "I am very happy here and have no complaints at all". People looked well cared for. We observed some people sat in the lounge watching television and talking and laughing with the staff. People also told us the food was very good one person said " the food is very good and you can have plenty of it". People all said the staff were very good and helpful.

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".

We spoke with a number of people who used this service, some told us they were very happy and felt they were having their needs met. Other people told us they were not happy at the home and were not having their needs met. All people told us that they were bored because there were little or no activities taking place. People said they enjoyed the food provided even if they were not aware what it was each day. We spoke to two visitors to the home. The first visitor said they were happy with the care their relative received and had no concerns or complaints. The other visitor was very concerned about their relative because they felt the home could not meet their needs.

All people we spoke with praised the staff but said that they were always very busy.

We spoke to three people about their medicines. One person told us they were given tablets but they did not know what they were for.

People told us that they felt well cared for and some of their comments included:

‘they are all really helpful, both day and night staff, they are all as good as each other’, ‘they look after me well’, ‘they give me the help I need’.

People also told us that they like the food that is provided some of their comments included:

‘the food is very tasty’, ‘we always have enough food’ and ‘I have a choice of food’.

People told us they were happy and well looked after. We observed that people's appearance had improved and staff had taken time to make people look well presented. Some of the female residents were able to show us they had received nail care and had their nails painted.

On one of the visits it was a person's birthday and a tea party was due to take place. The cook had made a cake and party food. We heard staff and people singing happy birthday to the person.

However, we found that improvements are still required for the outcomes we inspected. The service has made some improvements since the inspection in January 2012.