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Upton Manor Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 20 November 2020

About the service

Waypoints (Upton) is a purpose-built nursing home registered to provide care for up to 67 people. The home was divided into five separate living units. At the time of our inspection there were 38 people living there. This was due to a major refurbishment that was taking place. The people living in the home had complex care needs associated with their dementia.

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

Governance and oversight of the service was not robust: shortfalls and concerns have been identified at this inspection which internal audits and assessments had failed to highlight. Where internal systems had identified issues that needed to be addressed, this had not been done in a timely manner, leaving known issues unresolved.

Since the last inspection, the ownership of the registered provider has changed. The transition between different policies, procedures and ways of working had left staff confused and uncertain.

Systems and management of areas such as the administration of medicines, infection prevention and control and matters relating to the safety of people and the environment were not satisfactory. Records did not show people received their medicines in the way that they had been prescribed, appropriate infection prevention measures were not always maintained and checks and tests of important areas such as fire prevention were not always completed.

Risks to people’s health and wellbeing were not consistently managed. As well as living with dementia, many people lived with other conditions or specific needs. We could not be certain that people received the correct support to manage conditions such as diabetes or epilepsy or that areas such as moving and assisting people, preventing skin damage or dehydration were managed effectively.

Staff had not received the required training and competency checks to ensure they had the necessary skills to meet people's needs.

Staffng was provided in accordance with the provider's own policy and assessment tools. We identified times where, due to some people's needs, staff were not always be available for everyone in the home.

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

Rating at last inspection

The last rating for this service was good. (Published 28 August 2019)

Why we inspected

We received concerns in relation to people not receiving the care they needed, staffing and poor management. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating 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 coronavirus and other infection outbreaks effectively.


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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to infection prevention and control, medicines management, assessment of risk, consent, safe recruitment of staff and governance of the service.

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

The overall rating for the s

Inspection areas



Updated 20 November 2020

The service was not safe.

Details are in our safe findings below.



Updated 20 November 2020



Updated 20 November 2020



Updated 20 November 2020


Requires improvement

Updated 20 November 2020

The service was not always well-led.

Details are in our well led findings below.