All inspections: Upton Cottage - Care Quality Commission

Date of assessment 4 June to 17 June 2025. Upton Cottage is a residential care home which can accommodate up to 16 people. The service provides personal care to adults with learning disabilities. Fourteen people were living at the service at the time of the inspection. The assessment was carried out to follow up our previous inspection findings of a breach of good governance. At this inspection we found improvements were still needed to the provider’s governance arrangements as they had not identified shortfalls found during this inspection. We identified a new breach of legal requirements relating to the environment and premises.

We found as part of this inspection improvements were needed to the governance systems. The audits in place did not identify the improvements needed to; the safe handling of laundry, radiators that posed a risk of scalding and shortfalls in the management of medicines and incident and accidents. Staff also needed training specific to people they support along with an annual appraisal. Staff felt supported and able to raise concerns with the registered manager and provider, although staff felt there were not always enough staff when other staff were off. The registered manager and staff supported people in a kind and caring way, providing people with reassurance when required. People were supported by staff who new them well, and people were supported to attend health appointments and annual health checks when required. People’s care plans confirmed how to support the person with their individual needs. Although 1 person’s care plan needed improvements to their diabetes care plan. Mental Capacity assessments and best interest decisions were in place for people if needed. The registered manager made deprivation of liberty safeguard referrals as required. We assessed the service against ‘Right support, right care, right culture’ this is guidance to make judgements about whether the provider was supporting people with respect, equality, dignity, choice, independence and good access to local communities that most people take for granted. We found improvements were required to the quality assurance systems, the environment, staff training and the management of medicines, to ensure people got the right support and the right care. We have asked the provider for an action plan following this inspection.

About the service

Upton Cottage is a residential care home providing personal care to up to 16 people. At the time of our inspection there were 16 people using the service. The building is over 4 floors with a conservatory, dining area, lounge and offices in the basement area.

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

Right Support:

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. Although we found some improvements were required to the quality assurance systems relating to the management of medicines, risk assessments, and the safe disposal of personal protective equipment.

Right Care:

People were supported to receive person centred care that promoted their dignity and privacy and encouraged their independence. People were supported by staff to attend appointments and have referrals to health and social care professionals. People’s care plans contained important information such as likes and dislikes and their individual routines.

Right Culture:

People were supported by staff and management who knew them well. People’s views were sought through customer satisfaction surveys and meetings. People were spoken with in a calm and respectful manner. People were encouraged to be independent including accessing the local community such as shops, restaurants and use public transport if safe to do so.

Rating at last inspection and update

The last rating for this service was Good August 2017. At this inspection we found the service was requires Improvement.

Why we inspected

This inspection was prompted as we had not inspected this service since 2017.

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 see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified a breach in relation to regulation 17 good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety.

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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

This inspection took place on the 30 August 2107 and was unannounced. When the service was last inspected in June 2016 we found one breach of the regulations of the Health and Social Care Act 2008 and one breach of the CQC (Registration) Regulations 2009. The breaches related to good governance and statutory notifications of incidents. These breaches were followed up as part of our inspection.

You can read the report from our last comprehensive inspection, by selecting the 'All reports' link for Upton Cottage, on our website at www.cqc.org.uk

Upton Cottage is registered to provide accommodation and personal care for up to 16 people with learning disabilities. At the time of our inspection there were 16 people living at the service.

A registered manager was in post at the time of inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are “registered persons”. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our previous inspection there was not an effective system in place to monitor and identify issues with the building and infection control procedures. At this inspection we found sufficient improvements had been made. People were cared for in a safe, clean and hygienic environment.

At our previous inspection the service had not submitted statutory notifications of incidents as required by the CQC (Registration) Regulations 2009. Statutory notifications are information about important events which affect people or the home, which the service is legally obliged to submit. We found sufficient improvements had been made. The registered manager sent appropriate notifications to the Care Quality Commission.

Records showed that a range of checks had been carried out on staff to determine their suitability for work. Staffing numbers were sufficient to meet people’s needs and this ensured people were supported safely.

Risks to people were assessed and where required a risk management plan was in place to support people manage an identified risk and keep the person safe.

People’s rights were being upheld in line with the Mental Capacity Act 2005. This is a legal framework to protect people who are unable to make certain decisions themselves. We saw information in people’s support plans about mental capacity and Deprivation of Liberty Safeguards (DoLS). DoLS applications had been applied for appropriately. These safeguards aim to protect people living in services from being inappropriately deprived of their liberty.

People had their health needs monitored. People had access to healthcare professionals according to their specific needs.

Where appropriate people were encouraged to maintain contact with their family and were therefore not isolated from those people closest to them.

Staff were caring towards people and there was a good relationship between people and staff. People and their representatives were involved in the planning of their care and support. Staff demonstrated and in-depth understanding of the needs and preferences of the people they cared for. People were treated with respect and dignity.

Support provided to people met their needs. Supporting records highlighted personalised information about what was important to people and how to support them. People were involved in activities of their choice.

Staff described the registered manager as supportive and approachable. The registered manager encouraged an open line of communication with their team.

There were systems in place to assess, monitor and improve the quality and safety of the service.

We carried out this unannounced inspection on the 21 and 26 January 2016. At our last inspection in November 2013 the provider was found to be meeting all of the standards inspected.

Upton Cottage residential home provides accommodation for up to 16 people who have a learning disability and who require personal care. At the time of our visit there were 16 people living at the home. Upton Cottage residential home had 16 bedrooms some with en-suites, a staff room, kitchen, dining area, two lounges, office, entrance hall and hall way with a piano, gardens to the front and patio and garden area to the rear of the building.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are registered persons. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was present during the inspection.

The building was not always clean and properly maintained to ensure care was delivered safely to those living there, although people and relatives felt safe. The registered manager took quick action during our inspection and improvements had been made by the second day of our inspection. Improvements included the two mouldy towel rails being removed, bathrooms being cleaned and locks fitted to doors, radiators being bled to provide effective heating and some walls being repaired. People had a personal evacuation plan in place should there be an emergency; and incidents and accidents were reviewed. There was no over view of these incidents and accidents so that any similar incidents could be prevented, the registered manager confirmed they would review this. There was a safe system in place for the recruitment of new staff.

The service was raising concerns with the relevant safeguarding local authority but had not made notifications to the Care Quality Commission when concerns relating to safeguarding adults and abuse had been identified. People were supported by staff who had received training, supervision and regular meetings. Staff sought people’s consent to care and treatment this was sought in line with legislation and appropriate paperwork was in place and staff were able to demonstrate how they give people choice.

People and relatives were happy about the care they received and care provided. Staff demonstrated a kind and caring approach with people and were given daily choices so they were involved in decisions about their care and support. People received support from staff who knew them well. People were treated with dignity and respect by staff and people were supported to maintain relationships important to them. There was enough staff to ensure people had access to community and their one to one support although at times this was provided by the registered manager.

Relatives and staff all felt happy with the registered manager and provider of the home. The registered manager confirmed how important people were and that their vision was to ensure people had the care and support they required. People were supported to access activities that were important to them and this was reflected in their care plan.

People and relatives were involved in the care planning. There was a complaints policy in place along with an easy read version all people we spoke with were happy to make a complaint should the need arise.

Although there were systems in place to monitor areas of the service, we found the building and the infection control did not have an audit that identified areas of concern found during this inspection. There was a system in place to gain views from people, relatives, and professionals as there was an annual survey collated and a compliments and complaints box within the main reception of Upton Cottage.

You can see what action we told the provider to take at the back of the full version of the report.

We spoke with seven people who used the service to find out their views of Upton Cottage and what it was like for them to live there.

We used a number of different methods to help us understand the experiences of people who used the service, because they had complex needs which meant some people were not able to tell us their experiences. We relied on our observations and discussions with staff to understand the experience of care for those people living in Upton Cottage.

People were satisfied with the choice of meals at Upton Cottage. The staff understood how to effectively support people with their nutritional needs.

People were protected from the risks of unsuitable staff being employed at Upton Cottage because there were effective recruitment and selection processes in place.

The quality of the service people received was being effectively monitored and reviewed. The quality monitoring process involved seeking the views of people who used the service as well as those who represented them.

We spoke with four out of the fourteen people who used the service. They told us staff were kind and caring and that they were given the support to be independent and learn new skills. One person said "I am very happy here. All the staff are lovely. They help me with showering. All are very supportive". We also spoke with one relative who said " Staff are fantastic. They are warm, friendly and communication with families is good". Although the people who used services in the home told us they were happy and we saw that they were well supported; we found that failures to carry out risk assessments and conduct regular reviews might mean that people were not getting the support they needed. We also found failures to maintain a safe environment and gaps in the recruitment system which might put people at risk.

We met and talked to seven people who use the service and they told us that they felt included in decisions about their care.

People told us that they felt safe at the home and that staff 'are my friends".

People told us that the food was 'good' and that there was plenty to eat at times that suited

them. There was assistance for them to maintain their personal hygiene and that their

privacy and dignity was respected. People told us that their rooms were warm and

comfortable.

These older reports are from our old approaches to inspection, including those from before CQC was created.

Upton Cottage

All Inspections

During an assessment under our new approach

23 June 2023

During a routine inspection

30 August 2017

During a routine inspection

21 & 26 January 2016

During a routine inspection

15 April 2013

During a routine inspection

8 November 2012

During a routine inspection

14 December 2011

During a routine inspection

Reports under our old system of regulation