CQC report explained · a residential care home
What the CQC found at Upton Cottage
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, August 2023
Rated Requires Improvement; inspectors found kind, personalised care but weaknesses in medicines, risk records and quality checks.
The inspection was unannounced and took place on 23 and 26 June 2023. One inspector spoke with eight people, staff, relatives and a health professional. They also checked care plans, staff files and quality records.
The home was rated Good for Effective, Caring and Responsive. People were treated respectfully, supported to make choices and helped to access activities, family and health services.
Safe and Well-led were rated Requires Improvement. Medicines records were not always accurate. Some risk assessments were incomplete, and personal protective equipment was not always disposed of correctly. The home’s checks had not found these problems before the inspection.
The overall rating changed from Good at the last inspection in August 2017 to Requires Improvement. The provider must send CQC an action plan, and CQC will monitor the home and check whether improvements are made.
Kind and respectful care
People were supported by staff who knew them well and spoke to them calmly. Their privacy, dignity and choices were respected.
“People were supported by staff who spoke with them in a respectful manner.” from the report
Personalised support
Care plans included important details about people's routines, preferences, health needs and goals. Staff supported people to make daily choices.
“People's care plans contained important information such as likes and dislikes and their individual routines.” from the report
Independence and community life
People were encouraged to do things for themselves, including making breakfast, shopping, travelling by bus and taking part in local activities.
“People were encouraged to be independent including accessing the local community such as shops, restaurants and use public transport if safe to do so.” from the report
Support with health needs
People were supported to attend medical appointments and work with health and social care professionals. Staff had training relevant to people's needs.
“People were supported to live healthier lives and access health care services and support as needed.” from the report
Medicines records
seriousMedicines were being signed for before people had received them. Records did not always show when medicines were declined or where creams and pain patches had been applied.
“Their Medicines Administration Chart (MARs) had already been signed to say they had received their medicines.” from the report
Incomplete risk assessments
needs fixingSome personal and environmental risk assessments needed more information or had not been completed. This included emergency evacuation plans and the use of office stairs.
“Some risk assessments for people and the environment needed updating and implementing.” from the report
Quality checks
seriousThe home's audits had not identified the medicines, risk assessment and PPE problems before inspectors found them. This led to a breach of Regulation 17.
“The provider had failed to ensure adequate systems and processes were in place to assess, monitor and improve the quality and safety of the care provided.” from the report
- 01What changes have been made to ensure medicines are recorded only after they have been given, and how are declined medicines recorded?
- 02How are the locations of creams and pain patches recorded now?
- 03Have all personal evacuation plans and environmental risk assessments been reviewed and updated?
- 04How do managers now check that PPE is disposed of correctly and that infection control procedures are followed?
- 05What action plan was sent to CQC after the Regulation 17 breach, and what progress has been made?
This was an unannounced inspection of all five key questions, including infection prevention and control; the previous overall rating was Good in August 2017. This explanation was written from the published report of 4 August 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, October 2017
Upton Cottage was rated Good; inspectors found safe, kind and personalised care, with previous governance problems improved.
This was an unannounced inspection on 30 August 2017. One inspector spoke with six people, five staff members and the deputy manager. They observed care and reviewed five care plans, medicines records, staff records and documents about quality and safety.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines practice, suitable support for health needs, respectful relationships and care plans that reflected people's choices.
At the previous inspection in June 2016, the home had breached rules about good governance and reporting important incidents. Inspectors found that sufficient improvements had been made. The home was clean and safe, and the required notifications had been sent.
Safe staffing and medicines
There were enough staff to meet people's needs. Medicines were given as prescribed, records were completed accurately and monthly audits were carried out.
“People were protected against the risks associated with medicines because there were appropriate arrangements in place to manage medicines.” from the report
Personalised support
Care plans included personal communication needs, routines, likes and dislikes. People were supported to choose activities such as work, day services, shopping and arts and crafts.
“Each person's care plan included profiles which included what was important to the person and how best to support them.” from the report
Kind and respectful care
Inspectors saw warm, relaxed interactions. Staff supported people's independence, respected privacy and treated people with dignity.
“We observed people being treated with respect and dignity.” from the report
Previous problems addressed
The home had improved its checks on the building and infection control. It was also sending the required notifications about important incidents.
“At this inspection we found sufficient improvements had been made.” from the report
Toiletries stored in a bathroom
minorSome toiletries could have been shared, creating a cross-infection risk. The deputy manager removed them during the inspection.
“To ensure they would not be shared increasing the risk of cross-infection the deputy manager removed them immediately.” from the report
Bowel and food charts
needs fixingThe home's audits identified that completion of some bowel and food charts needed to improve. Ask how this was corrected and checked afterwards.
“An example of this included the need to improve the completion of bowel and food charts.” from the report
- 01How did you improve the completion of bowel and food charts after the inspection?
- 02How do you now check that toiletries and other personal items cannot be shared?
- 03What changes have been made since the previous inspection's problems with building, infection control and statutory notifications?
- 04How are people's individual communication needs, preferences and activity choices recorded and kept up to date?
- 05How are people and their relatives involved in care reviews and decisions about future goals?
This was an unannounced inspection covering all five key questions and following up breaches found at the June 2016 inspection. This explanation was written from the published report of 7 October 2017 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Upton Cottage
3 rated inspections over 7 years: the service has held its Requires improvement rating throughout.
- August 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 5 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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23 live-in carers within about an hour of North Somerset
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,050 to £1,320 a week. 19 can care for a couple. 12 years' experience on average.
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.