Upton Cottage

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question as requires improvement and the provider was in breach of legal regulation in good governance. At this assessment the rating has remained requires improvement. We found improvements were still needed to the provider’s governance arrangements around incidents and accidents, the environment, health and safety, and the management of medicines and 1 person’s care plan. The provider remained in breach of legal regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. The registered manager spoke passionately about always providing people with the best care possible. They were accessible to people and we observed them demonstrating kindness, compassion and supporting and reassuring people in a caring manner. The provider had a set of values they expected of staff. These included, supporting people with dignity, compassion, with integrity and to an excellent standard of care ensuring everyone feels included. Staff and the registered manager demonstrated this during our inspection.

The provider and the registered manager knew people, their families and staff well. All feedback we received was positive and confirmed the management of the service were always available and supportive. There was a deputy manager, a registered manager and the provider. All staff and people felt the management were good and it was a nice service. Staff told us, “It’s a nice place to work” and “There is amazing support (from management). All very good and supportive.” The registered manager was passionate about ensuring people got the best care and support possible at Upton Cottage and because some people had lived at the service for many years they knew people and their families really well. The service was managed by compassionate leaders who managed the service in an open and honest way.

The service had a positive culture where people, staff and relatives felt they could speak up and raise a concern should they need to. The registered manager and the deputy manager were available within the service, and families confirmed where they had needed to they had raised concerns with the provider and or the registered manager if needed.

Staff had daily handovers and team meetings were held every few months. Staff felt supported and able to raise any concerns with the registered manager if needed. Staff received regular supervisions, and these were an opportunity to discuss any areas of improvement, training and learning needs. The registered manager confirmed they reviewed staff performance through supervision rather than an annual appraisal. On reviewing staff supervision records it was not always clear how staff had met any identified areas of improvement or training. We raised this to the registered manager so they could review and take any actions needed.

The provider and registered manager valued staff, and they worked towards an inclusive and fair culture by improving equality and equity for those who worked for them. The registered manager gave examples of how they supported staff with a flexible approach to the shifts and hours they worked, and they gave an example where one member of staff was going to be increasing their hours.

Governance and management systems were still not always operating effectively to identify and mitigate risk to service users.

The service was managed by a provider, registered manager and deputy manager. Staff and the management of the service knew people well. Although the registered manager and the provider had a positive culture and knew people well. We identified the providers quality assurance system had not identified shortfalls found during our inspection. For example, we found one person’s care plan needed more information about how to support them with their diabetes care. Where concerns, incidents and accidents had occurred the quality assurance system around this did not always clearly document all information, and what actions had been taken by the service, including any outcomes and learning. We also found 1 notification had not been made to CQC as required. The governance arrangements had also failed to identify environmental risks and improvements, such as radiators that posed a scalding risk, the handling of laundry that posed an infection control risk. Improvements were also needed around the documentation and management of medicines. As well as the provider having a dependency tool to ensure they were able to demonstrate there were enough staff to meet people’s individual needs. The registered manager had an improvement list for the service. However, shortfalls found during our inspection had not been identified though governance arrangements and were not on the improvement list for the service. We shared our feedback with the registered manager so they could review areas of improvement needed to the providers governance arrangements. Following our inspection, they confirmed they had taken some environmental actions that posed a risk to people such as covering radiators and ensuring laundry was handled safely. They also confirmed they were reviewing various audits following our inspection.

The registered manager understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. They gave examples where they had worked with health and social care professionals to ensure people got the best care and support possible and to ensure people got health reviews when needed.

The registered manager was passionate about people getting quality care although some improvements were needed to demonstrate there was continuous learning and improvements across the service. For example, the system in place to monitor incidents and accidents did not always document learning and improvement undertaken or needed. We identified 1 incident that needed actions taking. We raised this with the registered manager so they could review how incidents and accidents were being managed and how they could demonstrate continuous learning and improvements made. The registered manager was open and transparent during our inspection and they spoke positively about making improvements needed following our feedback.