CQC report explained · a nursing home
What the CQC found at Upton Mill Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People told inspectors they felt safe. Risks such as falls, choking, diabetes and skin problems were assessed, medicines were managed safely, and infection control arrangements were in place.
- Effective?
- Good
- Staff received induction, training and support. People's nutritional, health and communication needs were assessed, and staff worked with health professionals when needed.
- Caring?
- Good
- People and relatives praised staff as kind and thoughtful. Inspectors saw staff treating people respectfully, offering choices and supporting independence.
- Responsive?
- Outstanding
- Care and activities were highly personalised, especially for people living with dementia. The home supported community involvement, flexible visiting and different ways of communicating.
- Well-led?
- Good
- The home had a clear management structure and regular audits, meetings and improvement plans. People, relatives and staff were able to give feedback.
What inspectors found, January 2022
Rated Good overall; inspectors found exceptionally responsive, personalised care, with staffing vacancies being managed through agency staff and extra hours.
This was the home’s first inspection since it registered. It was an unannounced comprehensive inspection on 10 and 14 December 2021. Inspectors spoke with people, relatives, staff and a health professional. They observed care, checked the building and reviewed care, recruitment, medicines and management records.
The home was rated Good for Safe, Effective, Caring and Well-led. It was rated Outstanding for Responsive. Inspectors found that people were safe, treated kindly, supported by trained staff and involved in decisions about their care.
The strongest area was personalised support, especially for people living with dementia. Activities were tailored to people’s interests and the home had strong links with the local community. The home had a COVID-19 outbreak among staff during the inspection, so some group activities were postponed and extra infection control measures were put in place.
Personalised dementia care
Staff adapted care and the environment to individual needs. Examples included a photographic clothing inventory, changes to crockery and flexible snacks and drinks.
“We found that staff had an excellent understanding of the adjustments that needed to be made to support people living with dementia to have a good day.” from the report
Meaningful activities
People were offered activities linked to their interests and abilities. The home also helped people take part in projects with local schools, businesses and community groups.
“People received a flower donation from a local supermarket and were supported to give back to the local community by creating homemade flower arrangements” from the report
Kind and respectful care
People and relatives praised staff, and inspectors observed polite, patient care. Staff asked permission, offered choices and supported people's independence.
“We observed people being treated with kindness and respect.” from the report
Strong quality checks
The home used audits, daily meetings and monthly clinical governance meetings to identify actions and monitor care.
“A robust system was in place to monitor and improve the quality of care people received.” from the report
Staff vacancies
needs fixingRecruitment was still under way. Agency staff were being used, managers were working on the floor and existing staff were doing extra hours to maintain staffing levels.
“Recruitment was ongoing to fill staff vacancies. In the interim agency staff were used to maintain the assessed staffing levels” from the report
Extra infection control measures needed
needs fixingThe home had a COVID-19 outbreak among staff. Inspectors asked for feedback to be acted on, and the home added more PPE stations and hand dispensers.
“The provider took immediate action to implement additional IPC measures following feedback and placed additional PPE stations and hand dispensers around the home.” from the report
End of life plans
minorNot everyone had an end of life care plan. The home said this was due to personal choice and encouraged people and relatives to discuss their wishes.
“Some people had End of Life care plans in place which captured their wishes and arrangements.” from the report
- 01How many staff vacancies are there now, and how often are agency staff used?
- 02How will you make sure care remains consistent when agency staff are working in the home?
- 03What infection control measures are currently in place following the COVID-19 outbreak?
- 04How are my relative's dementia needs, communication preferences and personal interests recorded and reviewed?
- 05How will you help us discuss and record my relative's end of life wishes?
This was an unannounced comprehensive inspection of the newly registered home, covering all five key questions, with movement in the home limited because of a COVID-19 outbreak. This explanation was written from the published report of 28 January 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.
What inspectors found, December 2020
Inspected but not rated; inspectors were assured about infection prevention and control.
This was an announced, targeted inspection on 30 November 2020. It looked only at infection prevention and control during the coronavirus pandemic.
Inspectors were assured that the home had suitable PPE, testing, cleaning, visiting and isolation arrangements. They found infection control audits and cleaning schedules, and staff had received relevant training.
People were supported with activities suited to their needs, including remote contact with relatives. The inspection did not give an overall quality rating or rate the other four areas.
Testing and outbreak response
Testing was carried out in line with best practice, with isolation and barrier nursing used when needed.
“The provider and registered manager ensured COVID-19 testing was carried out in accordance with best practice guidance.” from the report
Cleanliness and oversight
Inspectors found the home clean and hygienic. Managers used infection control audits and cleaning schedules to monitor standards.
“There were comprehensive infection control audits and cleaning schedules in place to ensure the home remained clean and the risk of infection was reduced.” from the report
Contact and activities
People had activities tailored to their needs and support to keep in touch with loved ones remotely. The home also arranged socially distanced visits and community activities.
“People were supported with an activities programme tailored to their needs, which included support to interact with their loved ones remotely.” from the report
Inspectors raised no specific concerns in this report.
- 01How have your infection prevention and control arrangements changed since the November 2020 inspection?
- 02How do you respond if a resident or staff member tests positive for COVID-19 or another infection?
- 03How do you make sure people can continue to see and communicate with their relatives when visiting restrictions apply?
- 04What activities are currently available for people living with dementia and for people receiving respite care?
- 05When was the home last inspected across all five CQC questions?
This was a targeted inspection of infection prevention and control only; the overall service and the other four questions were not rated. This explanation was written from the published report of 9 December 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 Mill Care Home
Each visit the CQC has published, newest first, back to the day the home was registered.
- January 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: OutstandingWell-led: Good
- December 2020Inspected but not ratedSafe: Inspected but not rated
- August 2020
Registered with the Care Quality Commission on 18 August 2020.
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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38 live-in carers within about an hour of Gloucestershire
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 £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
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.