Danesford Grange Care Home

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.
At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of legal regulation in relation to person centred care.
 

This service scored 32 (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 were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People did not consistently receive person-centred care. Care planning, risk management and daily care records failed to demonstrate people were always supported as individuals with unique needs, preferences and life experiences.

Care plans were generic, duplicated information across sections and contained conflicting information. This meant important information about people was not always clear or reflected within day-to-day care delivery. This increased the risk of staff relying on inaccurate information when supporting people.

People's emotional wellbeing was not always considered within care planning. For example, care records identified anxiety, distress and changes in behaviour for some service users. However, guidance for staff focused on recording behaviours rather than understanding triggers, reassurance techniques or personalised approaches to reduce distress.

Important information about people's backgrounds, routines and what mattered to them was not consistently embedded into care delivery. We found examples where meaningful information known about people had not been reflected within care plans or used to shape support.

Emergency planning was not person-centred. Personal Emergency Evacuation Plans (PEEPs) lacked detail about how individuals may respond in an emergency, how staff should communicate with them or what support may be required due to anxiety, cognitive impairment or communication difficulties.

People's healthcare needs were not always considered holistically. Care plans often described medical conditions but lacked clear guidance on how those conditions affected the person's daily life, wellbeing and support needs.

The provider had also removed its "resident of the day" process and no alternative system had been implemented. This reduced opportunities for structured review of people's changing needs, preferences and experiences.

There were significant shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not joined-up, flexible or supportive of choice and continuity.

Changes in people's health and wellbeing were not always reflected within care records or associated support plans. For example, changing mobility needs, pressure ulcer management, communication abilities and nutritional requirements were not consistently updated across records, resulting in gaps between assessed needs and planned care.

Communication between the service and external professionals was not always embedded into practice. Healthcare recommendations were not consistently in care plans, monitoring records or staff guidance, increasing the risk of inconsistent support.

The provider had not ensured effective oversight of external support arrangements. 1 service user received privately funded one-to-one support within the home. However, no formal agreement existed outlining responsibilities, accountability or governance arrangements between those involved in the person's care.

Accidents, incidents and significant events did not consistently result in reviews of care or risk management. Opportunities to update care plans, strengthen support arrangements and improve outcomes were missed.

We could not be assured care was planned, coordinated and delivered consistently. Poor integration, ineffective review processes and weak oversight increased the risk of people receiving inconsistent and unsafe care.

The provider did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

People and relatives were not always provided with clear and consistent information about care and support. Poor communication systems and inaccurate records reduced assurance people were fully informed about decisions affecting them.

People did not always receive up to date relevant information relating to any changes or information that needed to be shared. The provider lacked an effective system to ensure all people had access to information in a style that suited their needs.

People were not always provided with clear explanations regarding changes to their care. Records showed occasions where support arrangements, monitoring requirements and care interventions lacked clear rationale or explanation, reducing transparency and person-centred communication.

The registered manager was unable to evidence information shared with staff regarding improvement actions. Management reported training and improvement sessions had taken place following identified concerns. However, no records were available to demonstrate information had been communicated effectively or understood by staff.

The provider did not always make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not always involve people in decisions about their care or tell them what had changed as a result.

The provider did not consistently listen to, involve or act on the views of people using the service. Systems were not effective in ensuring people's experiences, wishes and feedback informed care planning, care delivery or service improvement.

Care plans often lacked meaningful detail about what was important to people, how they wished to be supported or how they preferred to make decisions about their care. Generic documentation reduced opportunities for people to have their voices reflected in the care they received.

People's views were not always evident when decisions were made about care and treatment. Records frequently focused on care tasks rather than individual wishes, preferences and desired outcomes. This limited assurance people remained at the centre of decisions affecting their lives.

We found examples where people had expressed dissatisfaction or concerns regarding their experiences within the service. 1 person told us, “We felt unhappy with how we were treated and do not wish to engage further”.

Whilst a suggestion box was available within reception, we saw no evidence of how feedback was analysed, acted upon or used to improve people's experiences.

The provider did not always make sure that people could access the care, support and treatment they needed when they needed it.

The provider could not demonstrate people always received equitable access to care, support and services which met their individual needs. Systems and care planning processes failed to consistently recognise and respond to differences in people's health conditions, communication needs and personal circumstances.

Care plans often lacked sufficient detail to ensure support was adapted to meet individual needs. Generic assessments and standardised approaches reduced assurance people received care tailored to their specific requirements.

People with communication difficulties were not always supported through clear and personalised guidance for staff. For example, documents identified some people experienced significant difficulties expressing pain, distress or changes in health. However, guidance on how staff should recognise and respond to these needs was limited.

People requiring specialist nutritional support did not always receive care consistently aligned with their assessed needs. Records showed prescribed supplements were not always recorded, preferred dietary options were not always provided and monitoring of food intake lacked detail. This increased the risk of inconsistent support for people with higher nutritional risks.

The environment did not consistently support equitable access for people living with dementia or cognitive impairment. Limited dementia-friendly signage and orientation aids reduced opportunities for people to navigate and engage with their surroundings as independently as possible.

Staff and leaders did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

The provider could not demonstrate people consistently experienced positive outcomes or received care which reflected their individual needs. Poor oversight, ineffective care planning and inconsistent care delivery created a risk of inequitable experiences for people using the service.

People with health risks and healthcare needs did not always receive consistent support. We found people living with serious pressure damage were not receiving care in line with their assessed needs, increasing the risk of avoidable deterioration of their health.

Outcomes for people were not routinely monitored or reviewed. Repeated falls involving some service users had not resulted in effective analysis, learning or preventative action, leaving people exposed to ongoing risks without evidence of improved outcomes.

People's health and wellbeing needs were not always met consistently. We found examples of prescribed nutritional supplements not being recorded, preferred nutritional support not being provided and monitoring records lacking sufficient detail to demonstrate people's needs had been met.

Access to meaningful end-of-life planning was inconsistent. People living with advanced health conditions had no end-of-life care plan in place, limiting opportunities to ensure future care reflected their wishes, values and preferences.

The provider failed to identify or address concerns which could negatively impact people's experiences. During this assessment we provided detailed feedback to the registered manager. Concerns remained despite assurances improvements had been made. This meant some people continued to experience poor outcomes linked to ineffective governance and care oversight.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

The provider did not consistently support people to plan for their future care and support needs. Opportunities to discuss, record and review people's wishes for future care were often missed.

End-of-life care planning was poor across the service. People living with advanced illnesses, significant frailty and deteriorating health conditions had no end-of-life care plans in place. This reduced assurance future care would reflect people's wishes, values and preferences.

Where plans were present, they often lacked meaningful detail about what mattered to the person. Important information such as personal wishes, cultural needs, spiritual beliefs, preferred place of care and choices regarding future treatment had not been fully explored or documented.

Care records did not consistently demonstrate people and those important to them had been involved in planning for future care needs. Discussions regarding anticipated deterioration, changing health needs and future decision-making were not always evidenced.

The provider had also failed to ensure care plans remained reflective of people's changing circumstances. We found examples of significant health changes, including pressure ulcers, increased frailty, communication difficulties and declining mobility.