Upton House

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 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The registered manager and staff had a shared vision and culture based on transparency, respect and trust. The registered manager told us in the Provider Information Return (PIR) that her ‘door was always open’ and staff confirmed this. The providers were visible and supportive. A staff member told us how the providers had supported them to develop and achieve care qualifications. We observed a clam and relaxed atmosphere throughout the day with staff supporting people in a respectful way. One person said, ‘This is the most wonderful place, beautifully clean. I can’t fault it.’

The provider had experienced leaders who understood people’s needs and had the skills and qualifications to support and develop staff. The registered manager had been registered with the CQC for 2 years and had several years’ experience of working in social care. We observed the registered manager was visible, working alongside staff in a supportive way. People described the registered manager as ‘a wonderful person’ and ‘very good.’ The providers were at the service regularly and it was clear they, and the registered manager, knew people and staff well.

There was a positive culture where people felt they could speak up and they would be listened to. People and staff told us they were confident to raise concerns and make suggestions to improve. Staff meetings were held and staff had a regular one to one meeting to discuss any issues and gain support. We heard examples of changes made based on people’s ideas and suggestions. The provider had a whistle blowing policy which staff were aware of. Complaints were investigated and responded to in line with the provider’s policy.

The provider valued diversity in their staff team which supported an inclusive culture. The provider had made some reasonable adjustments to ensure staff wellbeing and to support inclusion. A staff member told us how the adjustments meant they could remain at work and this made them feel valued. Staff had contracts and terms and conditions of employment.

The provider had clear roles, responsibilities and governance systems. The system to check the quality of the service had been improved. The registered manager had good oversight of the service and used this to manage any risks and to improve the quality of care. We sampled a variety of audits and checks and saw action was taken when issues arose. People told us they felt safe and knew the registered manager would act on any concerns they had. The registered manager submitted notifications to the CQC and others as required.

The provider and registered manager understood their duty to work in partnership with others to improve outcomes for people. They shared information and learning with partners and collaborated to improve the service. Records confirmed staff worked with GP’s and local health teams to improve people’s health and wellbeing. A relative confirmed staff had called a GP when their loved one was unwell and had kept them informed.

The provider focused on continuous improvement and learning across the service. They encouraged creative ways of improving people’s quality of life and used a survey system to gain people’s views. People and staff told us about suggestions they had made which had led to improvements. For example, changes had been made to the menu and bespoke portion sizes introduced based on feedback. Observations were used as part of the staff appraisal system to check staff competency and to give feedback about how to improve. The provider was a member of a care association which supported providers to be up to date with latest research and best practice.