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Upsall House Residential Home Limited Requires improvement

We are carrying out a review of quality at Upsall House Residential Home Limited. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary

Overall summary & rating

Requires improvement

Updated 11 May 2021

About the service

Upsall House Residential Home Limited is a care home providing accommodation and personal care for up to 30 people. At the time of our inspection there were 20 people using the service, some of whom were living with a dementia type illness. The home accommodates people in one adapted building over two floors.

People’s experience of using this service and what we found

Some improvements had been made to people’s care plans and individual risk assessments. Further information was required to record how people’s health conditions could impact upon their lives. We have made a recommendation about improving the quality of information contained in care records.

Infection prevention and control measures had improved. Visitors were robustly screened and improvements had been made to the environment. We were assured staff were wearing appropriate PPE. Further improvements were required to support good hand hygiene. We have made a recommendation about staff being bare below the elbow.

Medicines were stored safely and people received their medicines as prescribed. Further information was required to record the effectiveness of ‘as and when required’ medicines and where on the body creams were to be applied. We have made a recommendation about the recording of some medicines.

Increased auditing and monitoring checks were in place. Further actions were required to address the issues found at inspection. The provider's quality monitoring of the service had not been effective in identifying these issues. We have made a recommendation about quality monitoring.

People told us they felt safe. Staff understood their safeguarding responsibilities. Leadership and oversight had improved. Action plans had been put in place following the previous inspection. The service sought and encouraged feedback from people, staff, relatives and professionals.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was inadequate (published 22 December 2020) and there were multiple breaches of regulation. This service has been in Special Measures since October 2020. 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, safeguarding people from abuse, staffing, and good governance.

During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. This service is no longer in breach of regulations or in Special Measures.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to check whether the warning notices we previously served in relation to regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. This report only covers our findings in relation to the key questions safe and well-led which contain those requirements.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection (published 16 May 2019) for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection and our last focused inspection, by selecting the ‘all reports’ link for Upsall House Residential Home Limited on our website at

Follow up

We have asked the provider for an action plan. We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection areas


Requires improvement

Updated 11 May 2021

The service was not always safe.

Details are in our safe findings below.



Updated 11 May 2021



Updated 11 May 2021



Updated 11 May 2021


Requires improvement

Updated 11 May 2021

The service was not always well-led.

Details are in our well-led findings below.