Care Quality Commission

The Uplands responds to the 2020 CQC report

As many will know, inspectors from the Care Quality Commission (CQC) visited The Uplands earlier this year.

The subsequent report gave the Home an overall rating of ‘requires improvement’. It highlighted some areas that the inspectors felt were of concern as well as those where we did very well.
We felt that the report was far from balanced and contained many factual inaccuracies,all of which were appealed to the CQC. Sadly, however, the outcome remained the same. To say we were disappointed is an understatement.

We always pride ourselves with the highest of standards, however we acknowledge that on the day of the visit we did not manage to portray these standards to the inspectors.
We are disappointed – despite having shared all the information on the day and subsequently through the appeals process – that CQC would not accept any explanations or mitigation.
With this in mind, we are sharing the information and actions that were in place at the time but also further improvements we have made following the inspection.

Finally, when we shared the outcome of the inspection with staff, residents, and stakeholders earlier this year, the support and consistently positive feedback from everyone we spoke to was wonderful and this feedback very much continues.



CQC area of concern:

People living on the two dementia units did not experience a positive mealtime experience. Records failed to demonstrate that people at risk of malnutrition received a diet in accordance with their needs.


Our actions:

On the day of our inspection we felt that the inspectors did not account for the complex nature of our dementia residents.

Since the inspection, we have reflected upon our mealtime experience within our dementia units which has resulted in changes to ensure that the mealtime experience is as pleasurable as possible. This includes a complete redesign of the communal area with new kitchenettes and serving areas. Work to build these is due to start at the end of August.

People at risk of malnutrition have always been offered snacks but we recognise this could have been recorded better. Staff have been made aware and are working to ensure the correct information is recorded in their care plans.

We want to reassure that any residents at risk of malnutrition have fortified meals and drinks, and the GP will be aware if we have any concerns.



CQC area of concern:

Items were left out on the two dementia units which, if ingested, could pose a risk to people’s health and safety.


Our actions:

The one bottle of washing up liquid and a tub of drink thickener left out on the day of inspection on one unit were put away safely on the same day, as they had been left out in error.
Spot inspections ensure that items that may cause harm are no longer left out, and we’ve also purchased lockable boxes to house the thickeners for the units with tumbler locks within the kitchenette areas.

With regards to the safe management and administration of medication, we pride ourselves in being completely transparent.

We have a cutting-edge system to monitor our administration and stock of medicines. The CQC pharmacy inspector was given this information (which would not normally be available in care homes).

The inspector focused on any errors in stock counts and timings of administrations but failed to follow up any actions we’d already taken following our own internal audits.

If we had paper records or been less transparent all of the concerns would not have been identifiable in the audit – but this is not to say we aren’t always improving our processes and training.

This is, and has always been, monitored by regular auditing by the audit team and the Manager.

All medications are stock checked weekly and monitored.

Any discrepancies are fully investigated by senior staff. There is a documented audit trail of the investigations we have been carried out.

Part of this process looks at trends identified which are discussed in the meeting or as a result of individual supervisions.



Point of concern:

Systems to monitor the quality and safety of the service provided were not always effective in identifying shortfalls or driving improvements.


Our actions:

Essentially this is as a result of the two other points raised. We have an embedded the Care and Compliance audit tool that looks at all our systems and comprehensively audits all documentation. This involves follow-up actions and emails the owner of the actions. Actions are then fed back to the management meetings and the lessons learnt are then cascaded to the staff.

Spot checks are done on units by senior staff.

Mock inspections to see where we can improve more and constructive feedback to staff – the latest one was done in July 2020.

All medication stock checks are emailed to the Manager for transparency. Any discrepancies investigated.

Monthly management meetings all audits and findings, actions and results are discussed and disseminated. This allows/encourages all employees to raise issues and understand their role at Marches Care Limited.

Flash meetings with all staff now take place each week as another means of communication.