CQC report explained · a residential care home
What the CQC found at Upton House
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, May 2023
Upton House is rated Requires Improvement; care and leadership improved, but medicines, risk management and quality checks were still not reliable.
Inspectors made an unannounced focused inspection visit on 14 March 2023. They spoke with people, relatives and staff, observed care and checked care plans, medicines, recruitment records and management checks.
The home had improved since its previous inadequate rating. People said they were happy and felt safe. Visitors could visit when they wanted, staff recruitment was safer, and there were enough staff.
There were still important problems. Guidance about some health risks was not detailed enough, some weight and catheter records were incomplete, and medicines records did not always match the medicines supplied. Quality checks had not consistently found these problems.
The overall rating changed from Inadequate to Requires Improvement. The home had been in Special Measures but is no longer in Special Measures. The home remained in breach of Regulations 12 and 17, and the CQC asked for an action plan.
More open visiting
Relatives said they could visit whenever they wanted and visit people in their rooms. Restrictions on people’s movements had also been removed.
“The culture within the service was now open and transparent” from the report
Enough staff
Inspectors found enough staff to meet people’s needs. Recruitment checks had also improved, including references, employment history and DBS checks.
“There were enough staff to meet people's needs, who had been recruited safely.” from the report
Safeguarding improved
The home had systems to protect people from abuse, and the manager understood the responsibility to report concerns to the local safeguarding authority.
“There were now systems in place to protect people from abuse.” from the report
Better incident learning
Accidents and incidents were recorded and analysed for patterns. Action had been taken when reasons for falls were identified.
“Accidents and incidents were now recorded and had been analysed for any patterns or trends.” from the report
People supported with choices
Staff supported people to make their own decisions about activities and food, and followed the principles of the Mental Capacity Act.
“Staff supported people to make their own decisions including what they would like to do and what they want to eat.” from the report
Risk guidance was incomplete
seriousSome care plans did not say clearly how often people should be weighed or what staff should do after weight loss. Catheter care and skin-check guidance also had gaps.
“There was a risk people's weight loss would not be recognised and appropriate action would not be taken quickly, to reduce the risk to people's health.” from the report
Medicines records were not reliable
seriousSome medicine directions and names on records did not match the medicine labels. Stock records were also inaccurate, creating a risk that medicines were not given as prescribed.
“There was a risk people would not receive their medicines as prescribed.” from the report
Quality checks missed problems
needs fixingThe new audits were not completed consistently and had not identified the problems with medicines and care plans. The provider still needed to embed its monitoring system.
“The audits had not identified the shortfalls in the care plans and medicines.” from the report
Feedback had not been fully used
minorPeople, relatives and staff had been asked for their views, but the responses had not been analysed or linked to an action plan where needed.
“The results of these surveys had not been analysed or an action put in place if needed to address any concerns.” from the report
- 01What has been done to ensure every person at risk of weight loss is weighed as planned, and what action is taken if their weight falls?
- 02How are catheter drainage bags and skin checks recorded now, including for people who manage their own personal care?
- 03How do you check that medicine instructions and stock records match the medicines supplied?
- 04How often are quality audits completed, and how do you make sure they identify problems with care plans and medicines?
- 05How have feedback survey results been analysed and turned into actions?
This was an unannounced focused inspection of Safe and Well-led only; the other key-question ratings carried over from the previous inspection. This explanation was written from the published report of 16 May 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 2022
Upton House was rated Inadequate and placed in special measures; inspectors found serious safety, leadership and restrictions concerns.
This was an unannounced, focused inspection on 04 August 2022. Two inspectors spoke with people, relatives and staff, observed care, and checked care plans, medicines, recruitment files and management records.
Inspectors found people were at risk because incidents, distressed behaviour, falls, choking risks, medicines and fire safety had not been managed properly. Staff numbers were enough, but recruitment checks were incomplete. Visiting and going out were also restricted in ways inspectors said were not proportionate.
Leadership was rated Inadequate. The home did not have effective checks to find and correct problems, did not seek regular feedback, and did not always report serious incidents. The overall rating fell from Good at the previous inspection in 2018 to Inadequate.
Staffing levels
Inspectors found there were enough staff to meet people's needs. They also observed staff spending time talking with people and playing cards.
“There were enough staff to meet people's needs and our observation supported this.” from the report
Infection control
Inspectors were assured about the home's infection prevention measures, including PPE, testing, hygiene and managing possible outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
Everyday choices
Staff offered choices about day-to-day matters such as food. Inspectors also found that appropriate legal authorisations were in place where people were deprived of their liberty.
“Staff gave people choices when making day to day decisions such as what they would like to eat.” from the report
Restrictions on family contact and going out
seriousThe home controlled when, where and for how long people could receive visitors. People were also expected to ask permission to leave, which inspectors found was not a proportionate response to infection risk.
“The provider restricted where and how often people were able to have visitors and their ability to go out into the community.” from the report
Unmanaged incidents and behaviour
seriousIncidents of verbal and physical aggression, including punching, were not properly investigated or reported. There were no clear plans to reduce the risk of further harm.
“There had been numerous incidents of verbal and physical aggression from one person.” from the report
Medicines records and guidance
seriousThere was no clear guidance about when to give some medicines prescribed as needed. Medicine quantities and records were also inaccurate.
“Medicines were not managed safely.” from the report
Recruitment checks
seriousSome staff files lacked full references and employment histories. Gaps and previous conduct had not always been checked, which could allow unsuitable staff to work at the home.
“Staff were not recruited safely.” from the report
Weak leadership and monitoring
seriousAudits did not identify the problems found by inspectors. The home had not regularly sought feedback from people, relatives or staff, and serious incidents had not always been reported to CQC or safeguarding authorities.
“There was not an effective system in place to monitor the quality of the service, the service had deteriorated since the last inspection.” from the report
- 01What has changed to stop people being restricted from visiting family or going out without a proportionate reason?
- 02How are incidents of aggression, falls and distressed behaviour now recorded, reported and reviewed?
- 03Can you show the current risk assessments and care guidance for choking, catheters, diabetes and fire evacuation?
- 04How are medicines prescribed as needed now managed, including clear instructions and accurate stock records?
- 05What recruitment checks, audits, staff supervision and family feedback arrangements have been introduced since the inspection?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried over from the previous inspection in 2018. This explanation was written from the published report of 15 October 2022 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 House
5 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- May 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2022Inadequatedown from GoodSafe: InadequateWell-led: Inadequate
- November 2018Goodstayed GoodSafe: GoodWell-led: Good
- February 2017Goodstayed GoodSafe: Requires improvement
- April 2016GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- March 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 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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