Upton Cottage

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question as requires improvement. At this assessment the rating has remained requires improvement. We found improvements were needed to the environment such as surfaces that posed a scalding risk, bathroom doors that were being propped open and the unsafe handling of laundry that posed an infection control risk. The provider was in breach of legal regulation in relation to the premises.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have systems in place to ensure incidents and accidents were managed, so all actions and outcomes were documented along with any learning. For example, the registered manager confirmed with 1 incident they had reviewed a risk assessment and the person’s safety. This had not been documented. A different incident had an incident form completed by staff and had been raised with the local authority. Although no notification had been raised with CQC. The registered manager collated what incidents and accidents had occurred. This included when the incident had happened and who it had involved. However, there was no information of the type of incident and what actions had been taken including any outcome and learning. Not all incidents were collated onto the overall incident document. We asked the registered manager for more information about certain incidents as it was not always clear what actions they had taken. We were not always assured all actions were taken when required and incidents were being reviewed for any trends and analysis. This is important as trends can identify improvements needed across the service and to care provided. This also provides opportunities for continual learning. We raised this with the registered manager so they could review how they manage incidents and accidents including any actions and continual learning.

The registered manager worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. People had hospital passports within their care plan. These contained important information such as how to support the person if they were in hospital for any reason. Care plans had information such as any referrals made and outcomes of these. These included routine health screening appointments, annual health checks, eye and dental and appointments. Families confirmed people were supported with their health care and appointments when needed.

The registered manager confirmed they made referrals to health and social care professionals when required. Positive feedback has been provided by 2 professionals who confirmed they felt the service made referrals when required.

The registered manager worked with people and healthcare partners to ensure people’s care was safe. Although some improvements were needed to referrals and notifications being made when required. We found improvements were needed to the outcome of incidents so it was clear if a referral was needed to the local authority safeguarding team and if a notification had been made to Care Quality Commission (CQC) when required. We found 1 safeguarding notification had not been made to CQC when required.

Staff received training in safeguarding adults and staff knew the different types of abuse and who to report any concerns to. People felt safe and supported by staff who were kind and caring. One person when asked if they felt safe at the service, replied “Yes, safe here.” Another person told us, “They’re kind, they look after me.” Families felt the care provided by staff was very good. They told us, “Care is very good. They look after (name of the person) really well.” Another family member told us, “Care is good, (Name of the person) is really happy here.”

People’s care plans contained important information such as if the person was able to make their own decisions. Mental Capacity Assessments and best interest decisions were completed if required. The registered manager made Deprivation of Liberty Safeguards (DoLS) referrals, and they retained documentation whilst awaiting these to be reviewed and authorised.

People were supported by staff who knew them well and how to support people with any individual risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do things that mattered to them. People were encouraged to remain independent. Staff gave examples of how they encouraged people, such as promoting where they could do their own personal care and go out into the community by themselves.

People’s care plans were person centred and contained important information such as people’s likes and dislikes and what support people needed help with. Risk assessments gave staff information around how to support the person with any identified risks. Although we found care plans were detailed, 1 care plan needed more information on how staff were to support the person with their diabetes care. Such as what was the person’s normal blood sugars and what staff should do if they find the person’s blood sugar levels to be outside of the person’s normal range. We raised this with the registered manager so they could review this person’s diabetes care plan.

People were supported by staff who we observed were respectful and who provided reassurance to people when needed. Staff were provided with training in how to support people when they became upset, and they had also had training in mental health.

The provider was not ensuring the care environment and potential risks were being safely managed and shortfalls were being identified through health and safety checks and the providers environmental quality assurance systems.

Although we found the home clean and odour free improvements were needed. Dining room chairs as some had the covering split, and they needed to be replaced as they posed an infection control risk. The handling of soiled laundry needed improving as this was not being stored safely whilst waiting to be washed. We also found some improvements were needed to general maintenance around the building. It was not clear what water safety checks were being completed and if the checks being completed were adequate. Risks were also identified to bathroom doors as these were being propped open and could be difficult for people to close. We also found radiators could pose a scalding risk to people as these were uncovered.

We raised our concerns with the registered manager. Following our inspection they confirmed all radiators were covered, and they had completed a risk assessment for bathrooms doors that were propped open. They also confirmed water safety checks had been undertaken by an external company in January 2025 were being reviewed again following our inspection by an external company. They also confirmed bathroom doors were propped open to support people who might be at risk of falling. Although some improvements had been made to the environment following our inspection, we were not assured the provider was maintaining the building and the environment to a suitable standard. We were also not assured quality assurance systems were in place to identify shortfalls relating to health and safety and the environment. Improvements were therefore also needed to the providers governance arrangements and to ensure the environment was safe.

Building safety checks were in place for personal appliance testing (PAT) testing and regular fire testing was completed and people had personal evacuation plans in place in the event of an emergency.

The provider was not always ensuring staff had been provided with all mandatory training and an annual appraisal although staff had supervision and they felt supported. Staff had received training in infection control, epilepsy awareness, diabetes, safeguarding, mental capacity and deprivation of liberty safeguards. Although some improvements were needed to ensure staff received training and knowledge to support people with their individual needs. For example, staff had not received training in how to support people with a Learning Disability or Autism. This training is called Oliver McGowan training and is a requirement for all staff to complete. Staff had received training in Equality and Diversity, however when we spoke with staff around their knowledge of this it was limited. Improvements were therefore needed to ensure staff had appropriate training and knowledge suitable to their role.

People and families felt care provided by staff was good and that staff knew them well. During our inspection we observed people being supported to attend community activities, such as a day centre. Where people were independent accessing the community, we observed them going out into the community themselves. Following our visit to the service some families raised with us they felt the service might not always have enough staff to support people. This was with regard to one to one support they felt people should be getting and they were unsure if they were. We shared this feedback with the registered manager and with the local authority for them to review if people were getting their individual care and support as required. The registered manager confirmed they would review what support people should be getting and how staff were allocated. If needed they would implement additional documentation to demonstrate support being provided to people.The registered manager following our inspection confirmed, both people were being supported with one-to-one support although the service was only funded to support 1 person.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and they shared concerns with appropriate agencies as required. Staff had training in infection prevention control. They had access to personal protective equipment as required and there were clinical disposable bins to dispose of this safely.

People were supported to have annual vaccinations and where consent was needed this was gained.

The provider was not always ensuring documentation relating to the management of medicines was being completed, to demonstrate people got their medicines safely and when required and if not why. We were not assured there were suitable arrangements in place when people needed their medicines whilst out for the day, as staff did not always take the persons medicines with them. Improvements were also needed to the documenting of when topical creams need to be disposed of, if people had an allergy or not and for 1 person who had medicated toothpaste. These medicines shortfalls had not been identified through the provider’s medicines audit.

Staff had training in the safe administration of medicines, and they had their competencies undertaken to ensure they were competent in how they administered medicines.