Upton Dene Residential and Nursing Home

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

There was a breach of legal regulation in relation to good governance. The Local Authority visited the service in March 2024 due to a number of safeguarding concerns reported about the quality and safety of the service. At this visit, the Local Authority identified improvements across the service needed to be made. Following this visit, the provider put a service improvement plan in place to drive up improvements. At the time of our assessment, the service improvement plan was still in progress. During our visit, we found similar shortfalls in care planning, risk assessment, the implementation of the mental capacity act, staffing and good governance, as that identified by the Local Authority. We were concerned that improvements were not being made with any urgency. Record keeping was not always accurate or contemporaneous, which meant it was impossible to monitor the provision of people’s care with any certainty. Daily walkaround checks by the management team had failed to identify that some people’s pressure mattress settings were incorrect or that people had personal confidential information accessible in bedroom areas. Staff told us that the management team were approachable and felt supported in their job role. The culture of the service was open and transparent, and the service had a warm homely atmosphere. Both staff and people living in the home felt comfortable raising any concerns about the service and felt confident they would be acted upon. The service worked in partnership with other health and social care professionals to support people’s needs. There were systems in place to ensure that professional advice from other professionals was followed.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The management team acknowledged improvements to the service needed to be made. A service improvement plan had been developed in conjunction with the Local Authority and was in progress at the time of this assessment. The provider and management team had decided to not accept any more nursing admissions, whilst improvements were made. We discussed the concerns we identified with the systems in place to assess people's needs, care planning, risk management, consent, record keeping and governance with the management team. They were unable to explain why such shortfalls had been found but were committed to ensuring improvements were made. People and staff told us the management team were approachable and open to questions and suggestions for improvement. Staff told us the provider was a good company to work for and that staff morale was good.

There were processes in place to promote effective leadership. This included a range of audits to assess and monitor the quality and safety of the service and a supervision, appraisal and training framework to support staff development. Unfortunately, these processes were not always effective or implemented appropriately to enable shortfalls in service delivery to be addressed by the provider and management team. The manager told us they felt supported in their job role by the regional manager and other corporate teams.

Staff told us they felt able to speak up and felt they would be listened to.

There were appropriate policies and procedures in place to guide staff on how to ‘speak up’. This included safeguarding and whistleblowing polices and procedures. Staff told us they were aware of the provider’s safeguarding and whistleblowing polices and where to find them if needed. There was also a complaint procedure in place for people to use if necessary, and a grievance procedure for staff to follow if they had a workplace issue. Records of safeguarding allegations, care concerns, complaints and ongoing investigations was maintained. Staff meetings regularly took place and staff told us they felt able to discuss any concerns or issues relating to the running of the service.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The manager was supported in post by the regional manager and a deputy manager. Team leaders and senior care staff helped supervise care staff and care responsibilities on the floor. Corporate teams such as human resources and health and safety also supported the service. A service improvement plan had been put into place to improve the service with set timescales for completion. The management team told us care meetings had been increased; additional staff training in recording care, and additional supervision in wound management for the nursing team had been provided. At the time of inspection insufficient progress on making the improvements specified in the service improvement plan had been made. This was discussed with both the manager and regional manager

During our assessment we reviewed the provider's progress on their service improvement plan. We found insufficient progress had been made with reviewing and improving the accuracy of people's care information. As a result, some care plans and risk assessments were not up to date and contained contradictory information about the person. People with nursing needs also remained without adequate clinical care plans for some health and medical needs. This increased the risk of people receiving inappropriate and unsafe care and we would have expected the management team to have taken more urgent action in these areas. Although improvements to the manager's daily walkabout checks had been made, these daily checks failed to identify some people's pressure mattresses were on an incorrect setting or that some people's beds had not been correctly positioned against the wall to prevent a possible injury in the event of a fall. Some people in bed, did not have their bed brakes applied and some bedrooms contained personal confidential information accessible to visitors. This breached their right to confidentiality. These observations did not show the governance arrangements in place were robust at identifying and mitigating risks. Record keeping was not contemporaneous. This meant it was impossible to tell when people's care had been delivered to ensure it was given appropriately. Despite the audits in place, this shortfall had not been addressed to enable the management team to have a clear view of the care people received. The system in place to ensure the Mental Capacity Act and Deprivation of Liberty Safeguards were implemented effectively across the service was not adequate. As a result there were shortfalls in how and when this legislation was applied. Notifications regarding reportable incidents had been made appropriately to CQC. The culture of the service was open and transparent. The management team were committed to completing all improvements.

People told us they received support from other health and social care professionals such as their GP. They said there was a range of social activities on offer at the home to help them engage with others in the care home community.

Staff shared information with other health and social care professionals when making referrals for additional support.

The Local Authority told us that the management team were working proactively to improve the service. They said the management team usually worked collaboratively with them in respect of any safeguarding or quality concerns involving the service and people's care.

There were processes in place to guide collaborative and partnership working with other health and social care professionals.

The manager told us there was an electronic system in place called RADAR to record accidents and incidents. Accident and incidents were reviewed by the regional manager to ensure appropriate action was taken. There was little evidence however any learning from accidents and incidents were effectively shared and acted upon.

The process in place to prevent repeat events such as accidents and incidents, safeguarding or quality care concerns was not robust. A review of information held by CQC in respect of serious injuries and safeguarding events showed a repetitive cycle of recommendations made by the local authority in respect of care planning, escalating concerns, delays in seeking treatment, post fall management and record keeping. This had led to an organisational safeguarding being raised by the Local Authority in March 2024. This did not show the service promoted a culture of continuous learning and improvement. Concerns with the assessment of needs, care planning, risk management record keeping and consent and governance were found at this assessment by CQC. A service improvement plan was in place, but it was too early to tell at the time of our assessment if the lessons learnt, recommendations made, and improvements identified, had been embedded.