Danesford Grange Care Home

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

Effective – this means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has changed to Inadequate.

This meant there were widespread and significant shortfalls in people’s care, support and outcomes.

The service was in breach of legal regulation in relation to consent.

This service scored 38 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not make sure people’s care and treatment was effective because they did not check and discuss people’s health, care, wellbeing and communication needs with them.
People's needs were not effectively assessed or reviewed. Assessment processes failed to ensure care records were accurate, consistent or reflective of people's current needs.

Care plans and assessments contained conflicting, outdated and contradictory information, including records relating to mobility, communication, continence, capacity, nutrition and healthcare needs. This increased the risk of staff delivering inconsistent care.

Assessments were often generic and task-focused, relying on standard templates and yes/no responses rather than providing meaningful, person-centred guidance.
People's changing needs were not always recognised or reflected in care records. Repeated falls, pressure ulcers, deterioration in health, communication difficulties and nutritional concerns had not consistently triggered reviews or updates to assessments.

Mental Capacity Act assessments were frequently missing, incomplete or poorly completed, reducing assurance people's needs, wishes and rights were being properly considered.
Specialist advice and recommendations were not always incorporated into care planning, increasing the risk of staff not having clear guidance to meet people's assessed needs safely.
 

The provider did not plan and deliver people’s care and treatment with them. They did not follow legislation and current evidence-based good practice and standards.
People were not consistently receiving care and treatment based on current evidence, best practice or assessed need. Care planning, risk management and clinical interventions lacked detail, were often generic and did not always reflect nationally recognised guidance or individual healthcare requirements.

Care plans and risk assessments contained contradictory and inaccurate information, increasing the risk of incorrect care and treatment. Staff guidance was often unclear, particularly in relation to falls management, choking risks, pressure care, mental capacity and long-term health conditions.

People at risk of pressure damage were not consistently receiving care in line with assessed needs. We found gaps in repositioning records, people not always repositioned within prescribed timeframes and air mattresses set incorrectly against recorded weights. Internal monitoring had failed to identify these concerns, despite some people living with grade 3 and grade 4 pressure ulcers.
Specialist guidance was not always embedded into daily care provided. For example, care records did not consistently evidence recommendations from speech and language (SALT) professionals were being followed. People's dietary needs, preferred food choices and nutritional support were not always reflected in records reviewed.
Risk assessments lacked sufficient clinical detail and were often completed using generic yes/no formats. Choking risks, bed rail use, falls management and healthcare needs were not consistently assessed using a personalised approach, limiting staff understanding of how to safely support people.

Monitoring of health conditions was inconsistent. We found examples of pressure ulcer management, pain management, nutrition and medication monitoring where records did not provide assurance care and treatment remained effective or were regularly reviewed.
 

The provider did not work well across teams and services to support people. They did not share their assessment of people’s needs when moving between different services.
Staff teams and external professionals did not always work together effectively to ensure people received safe and coordinated care. We found at times poor communication between the team.
Staff understanding of people's needs was not always consistent. We found examples where care interventions, including repositioning, nutrition support and personal care, were not delivered in line with expected practice. This indicated poor communication between staff teams and ineffective oversight of care delivery.

Management oversight was not effective in bringing teams together to drive improvement. Concerns identified during the initial inspection remained present throughout the visits to the service, including issues relating to repositioning, records and risk management. This showed a failure to ensure management and staff worked collectively to implement and sustain improvements. Staff we gained feedback from told us management support did not always feel present and this did affect the staff teams morale.

Staff we spoke with were consistent on how they support each other, 1 staff member told us, “There is a strong team spirit, with staff supporting one another to ensure residents feel safe, valued, and as independent as possible”.
 

The provider did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. Staff did not always support people to live healthier lives, or where possible, reduce their future needs for care and support.

People were not consistently supported to achieve and maintain good health outcomes. Systems did not always ensure people's health needs, preferences and specialist recommendations were embedded into day-to-day practice.

People's nutritional needs were not always effectively supported. We found examples where prescribed nutritional supplements had not been recorded. Preferred foods and drinks were not consistently provided and food records lacked sufficient detail to demonstrate people had received the support required to maintain their health.

Specialist healthcare guidance was not always embedded into practice. For example, records showed recommendations from Speech and Language Therapists regarding eating, drinking and food textures. However, meal charts and observations did not always provide assurance these recommendations were consistently followed.

Health monitoring was not always effective. We found examples where pain management, pressure ulcers, nutrition and long-term health conditions were not consistently reviewed or monitored. Opportunities to identify deterioration to people’s health and respond promptly were missed.

Care planning did not always promote people's wellbeing and quality of life. For example, 1 person's documented food preferences were not consistently met.

Several people with advanced health conditions did not have end-of-life care plans in place. This limited assurance people had opportunities to discuss future healthcare wishes, preferences and choices about their care.

The provider did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and

consistent, or that they met both clinical expectations and the expectations of people themselves.

Systems to monitor safety, quality and outcomes were ineffective. The provider failed to identify, respond to and learn from concerns raised prior to and during this assessment, resulting in ongoing risks to people living at the service.

Repeated incidents did not result in meaningful review or improvement. For example, some service users experienced numerous falls over a short period. However, records failed to demonstrate effective analysis, learning or action to reduce future risk and improve outcomes for people.

Management oversight was poor. Required audits had not been completed, clinical monitoring had lapsed and senior staff were unclear regarding responsibilities for key quality assurance processes. This resulted in missed opportunities to identify poor practice and protect people from harm.

The provider did not tell people about their rights around consent or respect these when delivering care and treatment.
Mental Capacity Act (MCA) processes were ineffective. Capacity assessments were missing, incomplete, generic, undated or not decision specific. Best interest decisions frequently lacked evidence of involvement from family members, advocates or relevant professionals. This meant records did not demonstrate how decisions had been reached or why decisions were in the person's best interests.

We found examples where significant decisions relating to care, treatment, medication, placement and restrictive practices had not been supported by robust capacity assessments or best interest processes. Records often failed to identify the specific decision being assessed and lacked evidence less restrictive options had been considered.

How and who had the legal right to make decisions on people’s behalf was not clearly documented and evidence was not present in people’s care records around Lasting Power of Attorney (LPA) arrangements. We identified occasions where relatives were involved in decisions regarding hospital treatment and healthcare interventions. However, records did not always evidence their legal authority to make these decisions. This created a risk of decisions being made without appropriate consent or legal safeguards.

Records also contained conflicting information regarding people's ability to make decisions. For people who had been assessed as lacking capacity there was no clear evidence as to how a conclusion around their mental capacity had been reached.

Restrictive interventions, including bed rails and other safety measures, were not consistently supported by clear consent processes, capacity assessments or best interest decisions. Risk assessments were generic and failed to evidence consideration of people's rights and choices.
During the assessment we raised the concerns found around consent and best interest processes. The registered manager took no action to improve or assure us in this area.