Upton Grange Residential Home

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 requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 59 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was an effective system in place for staff to record accidents and incidents, including the actions taken in response. Management oversight enabled the identification of trends and themes, which supported learning and reduced the risk of similar events recurring. This learning was shared with the wider staff team, and people’s care plans were reviewed and updated to reflect any required changes.

The provider 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.

We reviewed documentation relating to the pre‑admission process and found this to be thorough and person‑centred. The registered manager told us prospective residents were offered the opportunity to visit for the day or undertake a trial stay. This enabled the service to assess whether their needs could be met and supported individuals to make an informed decision about moving into the home. Relevant information about new admissions was shared promptly with staff to ensure people received the correct care and support from the outset. For example, staff were informed in advance about one person’s disability, which helped prevent any communication difficulties on arrival. Where external referrals were required, these were completed in a timely manner and outcomes were clearly documented within people’s care plans.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People and their relatives told us they felt safe. Feedback included, “I have complete confidence in the home” and “Yes, [name] is 100% safe and everyone is so professional.” During the assessment, staff were observed interacting with people in a respectful manner and routinely checking on their safety. There were effective safeguarding systems and processes in place, and staff had received appropriate training. We saw that any allegations of abuse were reported promptly and managed appropriately.

The provider did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

One person’s care plan did not specify the required sling size or indicate which colour‑coded attachment point should be used to ensure safe use of the equipment. We did observe safe practices when staff assisted people with moving and handling and staff ensured people remained comfortable throughout. The omission within the care plan was addressed and the person’s plan was updated immediately.

Staff had a good understanding of the people they supported and were able to demonstrate detailed knowledge of individuals’ dietary needs.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During the assessment, we observed a fire exit from the kitchen opened directly into the residents’ lounge. To prevent people from entering the kitchen, staff had positioned a wheeled trolley in front of the door. While this reduced access to the kitchen, it also created an obstruction which could delay kitchen staff from exiting safely in an emergency. We raised this concern with the manager, who agreed to put a safer measure in place.

Fire drills were being completed regularly, and the service had taken timely action in response to recent fire risk assessment findings.

Regular health and safety checks were carried out, and all required safety certificates were in place and up to date. The provider had recently implemented a new digital system for reporting maintenance issues. This system, accessed by staff using a QR code, was easy to use and was operating effectively at the time of the assessment.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

We reviewed staff files and found evidence of safe recruitment practices. However, we identified some gaps within a small number of records. This was addressed immediately by the provider on the same day.

Supervisions were not always carried out at regular intervals. The provider had already recognised this and had introduced a new supervision matrix to improve monitoring and ensure consistency.

During the assessment, we observed there were sufficient numbers of staff on duty to meet people’s needs. Staff were consistently visible within communal areas and responded promptly when people requested assistance.

A comprehensive induction programme was in place to ensure new staff were adequately prepared before commencing their duties. Staff were undertaking newly allocated training to ensure they were equipped to meet the assessed needs of recent admissions.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. We observed some staff not following correct infection prevention and control procedures. For example, one staff member picked up a tablet without wearing appropriate personal protective equipment (PPE). This was fed back to the manager who said they would make improvements.

However, communal areas and equipment were kept clean and hygienic. Daily cleaning schedules were completed, and staff had received training in infection prevention and control. There were sufficient levels of PPE available for staff to access when assisting people.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

We identified inconsistent information regarding the application of topical creams, occasions where patch‑rotation guidance had not been followed, and a pharmacy warning that had not been transcribed onto medication records. We also found discrepancies in stock counts.

We discussed our findings with the registered manager who responded positively and confirmed that a full audit of medicines would be undertaken. A more robust system to monitor stock levels had also been implemented.

People received their medicines on time. Systems were in place for the ordering, storage and disposal of medicines, and the administration of PRN (as‑required) medicines was supported by clear protocols. Fridge temperatures were monitored and recorded daily.