CQC report explained · a nursing home
What the CQC found at Upton Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found robust risk assessments, improved medicines management, sufficient staff and effective infection control arrangements. They also found that restraint had reduced and that accidents and incidents were being reviewed.
- Effective?
- Good
- This area was not looked at during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This area was not looked at during this focused inspection. Its previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This area was not looked at during this focused inspection. Its previous rating was used in calculating the overall rating.
- Well-led?
- Good
- Inspectors found a new management team, effective audits, completed actions from the previous inspection and better staff morale. Records and notifications to the CQC were found to be clear and timely.
What inspectors found, August 2021
Rated Good; inspectors found major improvements in safety, medicines and management since the previous inspection.
This was an unannounced, focused inspection on 29 June and 5 July 2021. One inspector spoke with 15 staff members and two relatives. They reviewed recruitment files, care plans, risk assessments, training records, premises safety documents and management audits.
The home had improved substantially since September 2020. Inspectors found better risk assessments, safer medicines systems, improved infection control, suitable staffing and more effective checks on quality and safety. Care plans were person-centred and staff were safely recruited and trained.
The overall rating was Good. Safe and Well-led were both rated Good. The inspection did not assess all five areas, so the ratings for the other areas were carried over from the previous comprehensive inspection.
Risk management
Care and environmental risks were assessed properly. Staff had access to the information they needed, and falls and other incidents were reviewed to reduce future risks.
“Robust risk assessments were now in place. These covered people's care needs and the environment.” from the report
Medicines
Medicines were stored securely and administered using detailed, individual care plans. Electronic records and checks helped identify possible errors.
“The provider had a robust medicines policy and procedure and had good oversight of medicines practice.” from the report
Staff preparation
Recruitment checks were completed and new staff received training and a two- to three-week induction and shadowing period.
“Staff participated in an effective induction when they commenced in post. This included a mix of training and shadowing sessions” from the report
Management oversight
The provider had completed the action plan from the previous inspection. Regular audits were being used to identify problems and take action.
“Regular audits were undertaken to monitor all aspects of the quality and safety of the service.” from the report
Training still being completed
minorNot all staff had completed infection prevention and control training when inspectors visited. The report says 94% had completed it.
“94% of staff at Upton Manor had completed their infection prevention and control training.” from the report
- 01How will you keep staffing levels safe as you admit new residents?
- 02When will all staff complete infection prevention and control training?
- 03What checks are made after a medicines error, and how is staff competency reassessed?
- 04How will you make sure important information is not lost while the new electronic care planning system is introduced?
- 05What were the ratings for Caring, Effective and Responsive at the previous comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the ratings for the other areas were carried over from the previous comprehensive inspection. This explanation was written from the published report of 3 August 2021 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, November 2020
Upton Manor was rated Requires Improvement; safe care was rated Inadequate because of gaps in medicines, risk management, infection control and oversight.
This was an unannounced focused inspection. The inspectors looked at Safe and Well-led because concerns had been raised about care, staffing and management. They spoke with relatives and staff, observed care, checked records and continued parts of the inspection remotely because of the pandemic.
The inspectors found people were at risk because medicines, infection control, fire safety and care for conditions such as diabetes and epilepsy were not managed reliably. Records did not always show that people received medicines as prescribed or that risks such as choking, dehydration, pressure damage and moving people were properly managed. Staff training, recruitment records and competency checks were also incomplete.
Management oversight was not effective enough to identify and fix problems promptly. The provider responded during and after the inspection with actions including buying equipment, reviewing training and medicines systems, and creating an action plan. The home was asked to improve and CQC said it would monitor progress and return for another inspection.
Visiting arrangements
The home had arranged outdoor visiting and was creating an indoor visiting room for colder weather. Relatives gave some positive feedback about the response to COVID-19 measures.
“Arrangements had been made for outdoor visiting during the summer and a room was being converted during the inspection to enable safe visiting through the autumn and winter.” from the report
Safeguarding knowledge
The manager understood how to raise safeguarding concerns, and the local authority safeguarding team said the home worked well with them.
“The manager had a good knowledge of safeguarding and understood how to raise concerns with the local authority if this became necessary.” from the report
Immediate response
The provider acted during and after the inspection in response to several findings. Actions included buying equipment and reviewing training and procedures.
“The provider responded immediately during and after the inspection.” from the report
Working with other services
The home reported good support from GPs, other health services and social care staff. Inspectors also found the provider open to working with outside agencies.
“The registered provider and manager were responsive to the issues we raised during the inspection and very open to working with other agencies involved” from the report
Medicines were not reliably managed
seriousRecords showed gaps in medicines administration, unclear instructions for some medicines and unsafe arrangements for storage, patches, topical medicines and medicines that were crushed or given covertly. Inspectors could not be sure people received medicines as prescribed.
“We found no evidence that people had been harmed. However, systems were either not in place or robust enough to demonstrate that people received their medicines as prescribed.” from the report
Risks were not properly assessed
seriousCare plans did not contain enough detail for restraint, hoisting, pressure care, choking, diabetes, epilepsy or preventing dehydration. Some records did not show that staff acted when concerns were identified.
“We found no evidence that people had been harmed. However, systems were either not in place or robust enough to demonstrate that risks to people were appropriately assessed, planned for and managed.” from the report
Infection control gaps
seriousInspectors found problems with handwashing facilities, cleaning, social distancing, waste bins and the safe use of protective equipment. Not all staff had clear infection control training records.
“We were not assured that the provider was making sure infection outbreaks could be effectively prevented or managed.” from the report
Fire and emergency checks
seriousThe fire risk assessment was out of date and did not reflect building works. Evidence of required checks for fire systems, emergency lighting, electrical systems and other safety equipment was not provided.
“Evidence that the required tests and checks of the fire alarm system, fire doors and automatic door releases, sprinkler system, emergency lighting and firefighting equipment had been completed in accordance with government requirements was not provided.” from the report
Staffing and training records
seriousRecruitment and induction records were not provided. Training records were incomplete, and staff were not always available when several people needed support at the same time.
“Staff recruitment records were requested but were not provided.” from the report
Weak management oversight
seriousAudits did not identify all the problems found by inspectors, and some known issues were left unresolved. Staff were unclear about which policies and recording systems to use after the change in ownership.
“Governance and oversight of the service was not robust: shortfalls and concerns have been identified at this inspection which internal audits and assessments had failed to highlight.” from the report
- 01What changes have you made to medicines records, storage, pain assessment and checks on medicines given as required?
- 02How do you now manage diabetes, epilepsy, choking, pressure care and dehydration for each person?
- 03Can you show current evidence of fire safety checks, electrical testing and updated emergency plans?
- 04How do you check that permanent and agency staff have completed the training and competency assessments needed for this home?
- 05How are audits now identifying problems and making sure they are fixed promptly?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 20 November 2020 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 Manor
5 rated inspections over 6 years: the service has improved, from Requires improvement to Good.
- August 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2020Requires improvementdown from GoodSafe: InadequateWell-led: Requires improvement
- August 2019Goodstayed GoodSafe: GoodWell-led: Good
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2015
Registered with the Care Quality Commission on 13 March 2015.
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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15 live-in carers within about an hour of Dorset
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 £1,040 to £1,340 a week. 11 can care for a couple. 10 years' experience on average.
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