Danesford Grange Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

The provider had not established a positive learning culture. Incidents and accidents were not consistently reviewed, lessons were not embedded, and improvements were not sustained.
We found repeated examples where opportunities to learn had been missed. For example, where a service user had experienced 11 falls within a one-month period, there was limited evidence of meaningful review, updated risk management or preventative action. Furthermore, concerns relating to repositioning, pressure care, medication management and documentation had not been identified through internal monitoring.

Accident and incident records were of poor quality and often lacked sufficient detail regarding outcomes, actions taken and lessons learned. For example, incidents involving hospital admissions and emergency services attendance did not always clearly record outcomes or demonstrate how information had been used to improve care.

As a result, the provider could not demonstrate incidents and accidents were consistently used to drive learning, improve outcomes or reduce the risk of people experiencing harm.

The provider did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

Records contained conflicting and inaccurate information, meaning staff could not always rely on care plans and risk assessments to understand people's needs.
Risks were not consistently reviewed or managed following changes in care needs or incidents. For example, people experienced repeated falls, pressure ulcers and deteriorating health conditions, yet risk assessments and care plans were not always updated to reflect these risks or provide staff with clear guidance on how to manage these risks.

Health needs were not always safely managed. We found examples where repositioning records did not evidence people received care in line with assessed needs, despite some people living with grade 3 and grade 4 pressure ulcers. People who were at risk of choking had out of date Speech and Language Therapist (SALT) guidelines. This meant staff did not have up to date and safe guidance on how people should eat and drink safely. Care plans and risk assessments did not provide consistent information.

The provider had not ensured arrangements were in place where external care and support was being delivered within the service. For example, where people received privately arranged one-to-one support during daytime hours there was no formal agreement outlining responsibilities, accountability or oversight arrangements for the person.
 

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Staff understood how to report safeguarding concerns. However, staff did not always protect people from unsafe care and treatment.

We identified multiple concerns which placed people at increased risk of harm. These included significant gaps in repositioning records for people living with pressure ulcers, failure to evidence prescribed pressure care interventions, and air mattress settings being incorrectly set for individuals' weights. These issues had not been identified by staff despite risk of skin deterioration and further injury to people.

People experienced repeated falls without evidence of a review taking place, learning or preventative action. For example, where some service users experienced numerous falls over a short period of time, we found risk assessments remained generic, lacked person-centred detail and did not consistently demonstrate changes to reduce people’s future risk relating to falls.

The provider had failed to ensure lawful decision-making processes were followed for people who lacked capacity. Mental Capacity Act (2005) assessments and best interest decisions were incomplete, missing or poorly documented. We also found examples where family members appeared involved in decisions regarding healthcare treatment and hospital admissions without clear evidence of legal authority to do so. In these instances, care plans did not clearly show if people had mental capacity or not. This placed people at risk of decisions being made which may not reflect their wishes or best interests.

People were not consistently protected from neglect. We found evidence people had not received personal care, including records showing some people had not received showers for extended periods without explanation, review or documented agreement. Nutritional support was not always delivered as planned, including prescribed supplements and preferred food options not consistently being provided.

Risks associated with choking, bed rails, absconding and changing healthcare needs were not always adequately assessed or managed. Many risk assessments relied on generic yes/no formats and failed to provide meaningful guidance for staff. This meant we could not be assured staff had sufficient information to safely support people with high-risk health needs.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans lacked evidence of discussions around risks, preferences, choices and how people wished care to be provided.
Care plans and risk assessments were generic, contradictory and not personalised. Falls, choking and bed rail risk assessments relied heavily on yes/no responses and failed to describe individual risks or explain how people wished for those risks to be managed. Staff were delivering task-focused care rather than care based on individual wishes and needs.

We found examples where significant healthcare decisions were influenced by relatives, including decisions around hospital admission and treatment, and there was no clear evidence of legal authority through Health and Welfare Lasting Power of Attorney. This meant people were at increased risk of decisions being made without appropriate consent or legal authority.

People's preferences were not consistently reflected in care planning or daily practice. People’s records contained conflicting information regarding their ability to communicate their needs and make decisions. People’s food preferences were not reflected in care plans, which meant staff did not have information about the foods and drinks people preferred.

Restrictions used to manage risks were not always supported by clear evidence of people’s involvement or consultation. For example, for people identified as being at high risk of absconding, care records contained little information regarding discussions about risks, alternative options considered or how decisions around control measures had been reached.
 

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Environmental checks and management oversight failed to identify and act on concerns affecting people's safety and wellbeing.
We found worn and ripped furniture, damaged flooring, cluttered communal areas and inappropriate storage of equipment throughout the service. A broken fish tank, missing bathroom thermometers and environmental maintenance issues had not been identified or addressed through internal audits.

Equipment was not effectively monitored and maintained to ensure it was safe to use. Fire safety and environmental monitoring systems lacked oversight. Fire check records contained gaps and essential documentation. An up-to-date gas safety certificate was not readily available when requested.
The environment was not dementia-friendly, and considerations of décor and use of specialised colours and signs were not in place.
 

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

Staffing arrangements were not always effective. Whilst staff were observed to be caring and compassionate, staffing practices, oversight and competency arrangements were not always effective.
We found repeated gaps in repositioning records for people requiring 2-hourly and 3-hourly repositioning, including people living with grade 3 and grade 4 pressure ulcers and people receiving end-of-life care.

We were not assured staff were appropriately trained in moving and handling. We observed staff completing the task of hoisting, and observed poor communication between staff members, with staff not coordinating the moving and handling task effectively. This increased the risk of unsafe transfers and discomfort for people receiving support.
The provider could not evidence staff learning had been embedded into the care provided. Management advised mini-training sessions had been delivered following identified concerns. However, no records or evidence could be produced to confirm training had taken place or to demonstrate improvements in staff practice.

Management oversight of staff performance was ineffective. Clinical audits had not been completed as required, monitoring systems failed to identify poor recording practices, missed care, medication concerns, and issues raised during the initial inspection remained present during the follow-up visit.

Staff were recruited safely and all required checks were in place. This included staff having a police check (Disclosure and Barring Service, DBS), references and full employment history. There were enough staff to meet people’s needs. However, staff deployment around the service was not effective and at certain times, such as lunchtime, where there were not enough staff in the areas needed.
 

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We identified gaps in environmental oversight. Bathrooms had missing thermometers to check the temperatures of the water before people receiving personal care. We identified concerns regarding the cleanliness and maintenance of equipment, and a lack of clear monitoring records for some infection prevention measures. For example, staff advised a virus-killing unit required weekly cleaning. However, no records were available to demonstrate this cleaning had occurred.

The provider could not evidence they had implemented cleaning schedules. Equipment checks and infection prevention arrangements were not consistently reviewed or audited. The environment had cluttered areas, inappropriate equipment storage and areas of the home required maintenance and repair.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

Medicines were not managed safely. Systems and processes failed to ensure people consistently received medicines as prescribed and risks associated with medication administration were effectively monitored.

We identified medication errors, poor recording practices and weaknesses in medicines oversight. Examples included a prescribed medicine being administered at a different frequency to the pharmacy label instructions, a missed dose of prescribed pain relief and concerns regarding potential over and under dosing incidents. These incidents placed people at risk of avoidable harm.
Medication records did not always support safe administration. Medication Administration Records (MAR) charts contained inaccurate information, including incorrect room numbers and missing photographs of who the person administering to was, increasing the risk of medicines being administered to the wrong person. Records also failed to consistently record the actual time medicines had been administered. This increased the risk of people receiving medicines not in line with the prescriber’s instructions.

Topical medicines were poorly managed. Cream records contained amendments, crossings out and unclear instructions, with some changes lacking staff signatures. Prescribed creams stored in bedrooms did not always match instructions recorded on MAR charts. We also found a lack of body maps, reducing assurance staff applied creams to the correct areas and monitored skin conditions appropriately.

Medicine protocols lacked sufficient guidance for staff, increasing risk of inconsistent decision-making when administering medicines prescribed on an "as required" basis. Monitoring of pain management was ineffective, with limited evidence reviews had taken place to determine whether prescribed pain relief remained effective or whether changes in how the person presented required further clinical intervention.

Medication audits had not identified errors, recording issues or poor practice, resulting in missed opportunities to reduce risks and improve outcomes for people.