Upton House

Upton House is a residential care home providing personal care to up to 20 older people. The service provides support to people living with dementia in one large, adapted building. At the time of our inspection there were 17 people using the service.

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

People told us they were happy living at the service and felt safe. Since the last inspection, the provider had appointed a new registered manager and external consultant to drive improvement. This had been successful, and improvements had been made though further improvements were still needed.

Potential risks to people’s health and welfare had been assessed, but there was not always detailed guidance for staff to mitigate the risks. Medicines were not always managed safely, improvement was still needed to make sure records were accurate. There was now a system in place to complete checks and audits on the quality of the service. However, this was still being embedded and had not been consistent in identifying shortfalls found at this inspection.

The culture within the service had changed. Relatives told us they could now visit when they wanted and visit people in their rooms. They confirmed the culture within the service was now open and transparent, they had been invited to meetings to discuss what was happening within the service.

There were enough staff to meet people’s needs, who had been recruited safely. The registered manager understood their responsibility to report incidents to the local safeguarding authority and work with them to keep people safe.

People, relatives, and staff had been asked their opinion on the service, the responses had not been analysed to identify what action was required.

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 supported this practice.

Rating at last inspection and update

The last rating for this service was inadequate (published 15 October 2022) and there were breaches of regulation. At this inspection we found improvements had been made, but the further improvements were required, and the provider was still in breach of regulations.

This service has been in Special Measures since 14 October 2022. 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. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced focused inspection of this service on 4 August 2022. Breaches of legal requirements were found. 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 and improper treatment, fir and proper person employed and good governance.

We undertook this focused inspection to check 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. We have found evidence that the provider needs to make further improvements and remained in breach of regulations.

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 has changed from inadequate to requires improvement. This is based on the findings at this inspection.

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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Upton House on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to medicines and risk management and monitoring the quality of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Upton House is a residential care home providing personal care to up to 20 older people. The service provides support to people living with dementia in one large adapted building. At the time of our inspection there were 17 people using the service.

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

Relatives told us they felt their loved ones were safe living at the service. However, the culture within the service was controlling and restrictive. The provider restricted where and how often people were able to have visitors and their ability to go out into the community. People were required to ask permission to go out for social occasions. People and relatives had to agree to these restrictions to live at the service.

There was a closed culture within the service. The provider was insular and did not engage with outside agencies, such as, the local authority to keep up to date with changes and quality improvements.

Potential risks to people had not been assessed and managed to keep people safe. For example, there were no management plans in place to support people when they expressed distressed behaviours. Incidents of aggressive behaviour between people had not been managed and placed people at risk of injury. The registered manager had not recognised the need to report these incidents to the local safeguarding authority or the Care Quality Commission.

There was no effective system in place to monitor the quality of the service. Some audits had been completed but these had not identified the shortfalls found at this inspection. Checks had been completed on equipment, including weekly fire checks. However, there was not always documentation to show outside contractors had completed servicing.

There were enough staff to meet people’s needs. However, staff had not been recruited safely. Checks on staffs’ character, gaps in employment and conduct in previous social care roles had not been investigated, placing people at risk from receiving care from unsuitable staff.

Medicines were not managed safely. When people were prescribed medicines ‘when required’ for anxiety there was no guidance for staff about when and how often to give it. This placed people at risk of not receiving the medicine when they needed it.

The provider had not asked people, relatives, staff and other professionals their opinion on the quality of the service and any suggestions they may have.

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 22 November 2018).

Why we inspected

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.

We received concerns in relation to restrictions within the service including visiting. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 has changed from Good to Inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Upton House on our website at www.cqc.org.uk.

Enforcement

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 safe care and treatment, recruitment of staff and the leadership of the service at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Our last inspection on 20 December 2016 was a focused inspection to check the home was meeting the legal requirements following a breach from the previous comprehensive inspection on 10 and 11 March 2016. The breach was in relation to insufficient staff guidance for risk management and medicines not being managed safely. At the focused inspection we found improvements had been made and the provider had met the legal requirements with regards to risk management and the management of medicines. However, there was a recommendation for the provider to ensure all risk assessments were personalised and contained full guidance to reduce and mitigate risks to people. We therefore rated the home as Requires Improvement in the safe domain and it remained Good in all other domains and overall.

At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the home has not changed since our last inspection.

At this inspection we found the service remained Good.

The provider had acted on our recommendation. Risks to people were assessed on an individual basis and there was comprehensive guidance for staff. People were kept safe from avoidable harm and could raise any concerns with the registered manager. There was enough suitably trained and safely recruited staff to meet people’s needs. Medicines were administered safely and there was clear guidance for staff on how to support people to take their medicines. People were protected from any environmental risks in a clean and well-maintained home. Lessons were learnt from accidents and incidents.

People’s needs and rights to equality had been assessed and care plans had been kept up to date when people’s needs changed. Relatives we spoke to told us their loved one’s general health and wellbeing had improved since living at the home. Staff had the right induction, training and on-going support to do their job. People were supported to eat and drink enough to maintain a balanced diet and were given choice with their meals. People accessed the healthcare they needed and staff worked closely with other organisations to meet individual’s needs. People’s needs were met by the homes facilities and attention was paid to make the home ‘dementia friendly’. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the home supported this practice.

People and relatives we spoke with told us that staff were caring and the management team ensured there was a culture which promoted treating people with kindness, respect and compassion. Staff were attentive to people and everyone was clean and well dressed. The home had received positive feedback and people were involved in their care as much as possible. Staff protected people’s privacy and dignity and people were encouraged to be as independent as possible. Visitors were made welcome.

People received personalised care which met their needs and care plans were person centred and up to date. Where known, people’s wishes around their end of life care were recorded. Technology was used to enable people to keep safe and promote their independence. People’s communication needs were met and people were encouraged to take part in activities they liked. There was a good level of external entertainers brought into the home. There had not been any complaints but people could raise any concerns they had with the registered manager. The provider sought feedback from people and their relatives which was recorded, reviewed and used to make improvements.

The management team consisted of the owners, the registered manager, the general manager and team leaders. People and relatives were happy with the management of the home and staff understood the vision and values of the home promoted by the owners and management team. There was a positive, person centred and professional culture. The registered manager had good oversight of the quality and safety of the home, and risks were clearly understood and managed. This was supported by good record keeping, good communication and working in partnership with other health professionals. The managers promoted continuous learning by reviewing audits, feedback and incidents and making changes as a result.

Further information is in the detailed findings below.

Upton House can provide accommodation and personal care for 20 people living with dementia. The property is a large, Georgian style, listed building set in its own private well maintained

grounds. It is near to the village of Worth, on the main road between Deal and Sandwich. Accommodation is provided on two floors with stair lifts to enable people to access all areas of the service. There are two communal lounges on the ground floor, together with a large conservatory.

Rating at last inspection.

At the last inspection, the service was rated Good overall and Requires Improvement in the ‘Safe’ domain.

Why we inspected.

We previously carried out an unannounced comprehensive inspection of this service on 10 and 11 March 2016. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach of Regulation 12 of the Health and Social Care Act Regulated Activities Regulations 2014, Safe care and treatment.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Upton House on our website at www.cqc.org.uk

At this inspection we found the service had improved but there were still shortfalls in the safe domain. There was not a breach in the regulations but we have made a recommendation for the provider to improve. Therefore, the rating remained Requires Improvement in the Safe domain.

Why the service is rated Requires Improvement in the safe domain.

People told us they felt safe living at Upton House. Relatives were confident that their relatives were safe at Upton House and received the care and support that they needed.

At the last inspection the registered persons provider did not have sufficient guidance for staff to follow to show how risks were mitigated and managed. There had been some improvements and the service was now compliant with the regulations, but further improvements were needed for people living with diabetes as the guidance was generic and did not contain personalised information. When people were at risk of falling and needed support to mobilise, risk assessments did not include what action staff should take if people did fall.

The shortfalls in the risk assessments had not had a direct impact on people because staff knew people well. However, there was a risk that staff would not take the appropriate action to keep risks to a minimum as there was insufficient guidance.

Other risk assessments contained sufficient guidance on how to care and support people and keep risks to a minimum. People were positively supported with their behaviour. There was guidance in place about what action the staff needed to take to make sure the person and everyone else was safe. People’s risk assessments regarding the use of bed rails had been reviewed and measures were in place to reduce the risks of people falling out of bed.

Accident and incident records and monthly fall audits were reviewed. Any concerns were investigated and action taken to prevent the risk, however further analysis was required to look for patterns and trends to reduce the risk of re-occurrence. This was an area for improvement.

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At the last inspection the provider did not have safe systems in place to ensure that medicines were being stored and administered in line with current guidance. At this inspection improvements had been made and medicines were handled safely and appropriately by staff.

Staff knew how to recognise and respond to abuse. They had received training on how to keep people safe. Regular checks were made on the premises and equipment to ensure it was safe.

There were sufficient numbers of staff on duty at all times to ensure that people’s needs were met. New staff had been recruited safely and checks were carried out on staff to make sure they were suitable and safe to work with people.

Upton House is a privately owned care home for people living with dementia. It provides care for up to 20 older people. The property is a large, Georgian style, listed building set in its own private well maintained grounds. It is near to the village of Worth, on the main road between Deal and Sandwich. Accommodation is provided on 2 floors with stair lifts to enable people to access all areas of the service. There are two communal lounges on the ground floor, together with a large conservatory. At the time of this inspection there were 19 people receiving a service.

The service has a general manager and an established registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Potential risks to people were identified in all aspects of people’s care. However, there was not always full guidance for staff to follow to move people safely to show how the associated risks were being managed safely.

Medicines were administered safely. However, people did not always receive their medicines in line with safe infection control procedures because of the way some staff handled the medicines. The storage of the medicines was not in line with current legislation to ensure it was safe and secure at all times.

People and relatives told us they felt safe in the service. Although staff had received safeguarding training, and had an understanding of what constituted abuse, they were not all sure of the process to report any such concerns in order to keep people safe.

Records of accidents and incidents showed that action was promptly taken to investigate and implement measures to prevent re-occurrence. Health and safety audits of the environment and equipment were carried out regularly to make sure people were safe in the service. Fire tests and drills were held regularly but staff names had not been recorded to ensure that all staff had attended a drill. Environmental risk assessments were in place and each person had a personal plan to be actioned in the event of an emergency.

Some refurbishment of the premises had been carried out and plans were in place to further improve the environment. People’s rooms were personalised to their individual preferences.

Relatives and staff told us that there was always sufficient numbers of qualified, skilled and experienced staff to meet people’s care and support needs. Staff received ongoing training to ensure they had the skills and competencies to carry out their role. There was a programme of staff supervision and appraisal to discuss and identify any further training and development needs. There were systems in place to ensure that staff were recruited safely and ensure they were suitable to work at the service.

Staff were kind, compassionate and caring. They treated people with respect and ensured they received the care and support they needed. Staff encouraged people with their daily routines and encouraged them to remain as independent as possible. People and relatives told us that staff were respectful and their privacy and dignity were maintained.

People were supported to make their own decisions and choices, and these were respected by staff. Where people lacked the mental capacity to make decisions the registered manager was guided by the principles of the Mental Capacity Act 2005 to ensure any decisions taken were made in the person’s best interests. Staff understood the importance of supporting people to make decisions, however not all staff had an understanding of the process. The registered manager told us that Mental Capacity and DoLs training had been booked for all staff in March 2016.

People and relatives told us the food was good and there were choices at all meal times. Special diets were catered for and when required people’s food was fortified to help boost their dietary needs. Staff understood people’s likes and dislikes, and promoted people to eat a healthy diet.

People were supported to maintain good health and received medical attention when they needed to. Appropriate referrals to health care professionals were made when required. Care plans were personalised and had been regularly updated.

People’s preferred hobbies and pastimes were recorded in their care plans, and staff were able to tell us how they encouraged people to take part in activities of their choice.

People and relatives told us that they would not hesitate to complain if they had any issues. There was a complaints procedure in place, which was on display, so that people were aware how to make a complaint. There had been no formal complaints received about the service. There were some elements in the complaints procedure which required updating such as evidencing the responses to complaints and the outcomes. We discussed this with the registered manager who confirmed that this would be reviewed and updated without delay.

The service encouraged regular feedback from people, their relatives, staff and health care professionals, about the overall quality of the service. The registered manager worked alongside staff as part of the care team each week, during which time they observed the quality of care being provided. Audits and checks of the service were made on a daily basis to ensure the service was safe.

The registered manager provided leadership to the staff and there was a culture of continuous improvement, so that people would feel increasingly well cared for. Staff told us that the registered manager was very supportive; they knew the service well and strived to provide a good service.

The staff understood the vision and values of the service, such as person centred care, treating people with respect and maintaining their privacy and dignity.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

People we were able to talk with told us that the service responded to their health needs quickly and that staff talked to them regularly about their plan of care and any changes that may be needed. All staff spoken with demonstrated an appropriate level of experience and knowledge that enabled them to support people who lived at the service with their needs effectively.

We saw that the people who used the service were making choices about their lives and were part of the decision making process. People had their own individual routines which were respected. One person who used the service said "Staff are very good. I have no concerns". Another person said 'They look after me well here'. A relative said "The staff are very friendly they do a good job".Another relative said " The manager is doing a good job I have no concerns".

The service was clean and free from offensive odours. The medication was being handled appropriately and systems were in place to monitor the service that people received to ensure that the service was satisfactory and safe.

During our visit we spoke to two people who used the service and four members of staff including the manager. We looked at the views of relatives of people who used the service.

We saw care plans and health files in place for all people and these were regularly reviewed and changes made as necessary. We found that people were encouraged to be as independent as possible and to make their own decisions. Where this was not possible we found that best interest meetings and mental capacity assessments had taken place.

Staff were observed interacting with people in a relaxed and friendly way. They listened to people's requests and responded quickly.

We saw that people were treated with dignity and respect and had choice, and their views and needs were taken into account. We found that there were enough staff on duty to meet people's needs and that safeguarding issues were understood and addressed.

Records showed that staff had been properly recruited, trained and supervised. We found that the service monitored quality of care regularly and acted on any issues that had arisen.