Upton Grange Residential Home

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 requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (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 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 provider’s vision was to offer each person a safe and secure home, promoting a high quality of life when it was no longer possible for them to remain in their own home. This included maintaining dignity, privacy, individuality and opportunities for meaningful experiences. This ethos was evident during our assessment. Staff interactions demonstrated warmth, humour and inclusivity. One relative told us, "Upton Grange feels like a home not a hotel. I have recommended Upton Grange to others. I don’t think improvements are needed."

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff consistently spoke positively about the management team, noting that managers were responsive and supportive, commenting that, “They listen to you” and “We have good management.” Relatives also told us managers were accessible and professional in their approach, stating, “The management are great and deal with everyone professionally.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

There was an open and transparent culture within the service, where staff felt confident to report any concerns. Appropriate whistleblowing and safeguarding policies were in place, providing staff with clear guidance and reassurance on how to raise issues. Regular staff meetings were held, and staff told us they felt able to discuss any matters relating to the operation of the service. One staff member said, “I escalated a concern and it got sorted.” A formal complaints procedure was available for people using the service, and a grievance process was in place for staff to follow should they experience any workplace issues.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider promoted an inclusive culture and prioritised staff well‑being. All staff had access to an employee assistance programme which included access to a 24‑hour support helpline, with systems in place to maintain anonymity and confidentiality. Staff told us they had not experienced any issues relating to discrimination.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The manager acknowledged further work was required around medicine management and told us a comprehensive medicines audit was already underway and new systems and processes would be introduced to strengthen monitoring, oversight and governance.

Scheduled audits were in place to monitor the performance of the service. We did see evidence where other issues had been identified through internal audits, appropriate actions were taken. Trends and themes were analysed and fed into an ongoing action plan to support continuous improvement.

The provider 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.

Staff and leaders demonstrated an open and transparent approach and worked collaboratively with relevant external stakeholders and agencies. People’s care records showed appropriate referrals to external health professionals, and the professionals we spoke with provided positive feedback about the service. One professional told us they had “no concerns.”

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Learning was embedded within the service and supported continuous improvement and innovation. The organisation reflected on both positive and negative outcomes to understand their impact on people, and this learning was consistently used to shape and strengthen future processes. Ongoing improvement work included the installation of a new call bell system, refurbishment of bedrooms, and planned changes to the building layout to enhance accessibility for people living with dementia.