29 June 2021
During an inspection looking at part of 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.