Background to this inspection
Updated
13 April 2023
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
An inspector, a medicines inspector and an expert by experience carried out this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Upsall House is a ‘care home.’ People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Upsall House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
At the time of our inspection there was no registered manager in post.
Notice of inspection:
This inspection was unannounced. Inspection activity started on 23 June 2022 and ended on 18 July 2022. We visited the location’s service on 23 June, 1 July and 5 July 2022.
What we did before the inspection
We reviewed information we had received about the service since the last inspection. We sought feedback from Redcar and Cleveland local authority and professionals who work with the service, such as Cleveland Fire Service and South Tees infection prevention and control team. We used all this information to plan our inspection. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make.
During the inspection
We spoke to nine people who used the service and nine relatives. We also spoke with nine staff. These included the nominated individual, the manager, the deputy manager, a domestic member of staff and five care staff. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed four care records and nine medicine administration records. We reviewed seven staff recruitment records, induction supervision and appraisal records. We also reviewed the training matrix for all staff. We reviewed records relating to the day to day running of the service, including policies and procedures.
Updated
13 April 2023
About the service
Upsall House Residential Home Limited is a care home providing personal care for up to 30 people aged 65 and over. At the time of the inspection there were 22 people living at the service. The service accommodated people in one adapted building over two floors.
People’s experience of using this service and what we found
People’s care remained unsafe. Although people said they received good care from staff who knew them well, we found risks were not always anticipated or responded to. Staff were not supported with supervision, appraisal and training. Recruitment procedures remained unsafe. There were always enough staff on duty. Infection prevention and control measures had significantly improved.
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; the policies and systems in the service did not always support this practice.
Little improvement had been made since the last inspection. Leaders did not have the necessary skills and knowledge to deliver a safe service. Quality assurance measures continued to be ineffective and did not support the service to make continued improvements. The quality of the environment had started to impact upon people’s dignity.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was inadequate (published 7 January 2022). At this inspection we found the provider remained in breach of regulations.
Why we inspected
We carried out an unannounced focused inspection of this service on 15, 18 and 23 November 2021. Breaches of legal requirements were found. We served a warning notice. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, fit and proper persons employed and good governance.
We undertook this focused inspection to check they had met the requirements of the warning notice and they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains inadequate. This is based on the findings at this inspection.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Upsall House on our website at www.cqc.org.uk.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to recruitment and quality assurance procedures at this inspection. Whilst enforcement action was proposed and being processed, the provider submitted a Voluntary Cancellation of their registration and therefore our enforcement action did not proceed.
Follow up
The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures.’ The provider has submitted a Voluntary Cancellation of their registration.