Upton Manor

Updated 3 August 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection team consisted of one inspector.

Service and service type

Upton Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager who had applied to be registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return, PIR. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. The PIR had been submitted by a previous manager. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with 15 staff members who held various roles including the manager, quality service manager, registered nurse, hotel service manager, five care staff, called homemakers and chefs. The provider supplied our email and phone contact to relatives of people using the service however we received no responses. We did speak with two relatives at the service. We reviewed a range of records including the training matrix, premises safety documents, seven recruitment files, risk assessments and care plans. A variety of records relating to the management of the service, including policies and procedures and audits were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 3 August 2021

About the service

Upton Manor is a residential care home providing personal and nursing care to up to 67 people aged 65 and over. At the time of the inspection there were 26 people using the service. The service has purpose-built premises which is provided over three floors, two of which were almost vacant during our inspection. The upper floor accommodates people living with dementia and the provider intends to support people with residential and nursing care on the other two floors.

People’s experience of using this service and what we found

At our last inspection in September 2020 risks were not sufficiently managed, at this inspection improvements had been made. Robust risk assessments had been completed to minimise risks to people during care delivery or from the environment. The use of restraint had reduced and staff were supportive of people taking some risks in order to lead fulfilling lives. Management of healthcare conditions had improved, and person-centred care plans ensured care delivery was how people wanted it. Safety of the premises and of equipment was monitored. Staff were safely recruited and completed an in-depth induction and shadowing period on commencement. The provider was recruiting to staff vacancies before admitting new residents to the service to ensure staffing levels remained safe. At our last inspection, medicines had not been managed safely. This inspection found that significant improvements had now been made to the way in which medicines were administered and stored and the auditing procedures were more robust. At our last inspection we were not assured that infection prevention and control was effective. Improvements had been made and the provider was no longer in breach of this regulation. There had been concerns that suitable mental capacity assessments and best interest decisions had not been completed before including people in COVID-19 testing. There were now clear assessments in place which were in line with legislation.

At our last inspection we were concerned that a lack of oversight and auditing increased risks in the service. There have been significant improvements and we were now assured that audit processes were being used effectively to reduce risk and drive improvements. Relatives and staff were regularly asked to comment on the service. There were positive relationships with health and social care professionals.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was requires improvement (published 20 November 2020). There were multiple breaches of regulations. At this inspection we saw many improvements and the provider was no longer in breach of regulations.

Why we inspected

We carried out an inspection of this service on 17 September 2020. Breaches of legal requirements were found. The provider completed an action plan to show what they would do and by when to improve safe care and treatment, fit and proper persons employed, good governance and need for consent.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Upton Manor on our website at www.cqc.org.uk.