Danesford Grange Care Home

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• 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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 29 (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 shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The provider failed to create a culture focused on safety, quality and continuous improvement. Whilst staff were caring and committed to supporting people, this was not supported by effective leadership, clear direction or a culture of accountability.

Concerns identified during the assessment remained present throughout the visits, despite assurances and an action plan from management being presented. This included concerns relating to care planning, risk assessments, Mental Capacity Act processes, repositioning practices and end-of-life planning. This demonstrated improvement actions were not effectively implemented or embedded within the service.

Leaders had not established clear expectations regarding quality and standards. Poor practice, inaccurate records and missed care had not been identified through routine oversight. Staff continued to work with generic assessments, contradictory care plans and ineffective monitoring systems despite previous concerns being raised.

There was a disconnect between management assurances and the reality of care required within the service. For example, audits completed had failed to identify significant concerns found during this assessment.

Leadership oversight lacked consistency. Required audits had not been completed, responsibilities were not always clearly understood and opportunities to drive improvement had been missed. This resulted in a culture where concerns remained unresolved and poor practice became normalised.

Staff were observed to be kind and compassionate towards people living at the service. However, positive staff values were undermined by weak governance systems, ineffective leadership and a failure to sustain improvements.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

Leaders did not demonstrate the skills, oversight or effectiveness required to ensure people received safe, high-quality care. Although leaders spoke openly about challenges within the service, action taken to address concerns had been ineffective.

We identified a significant gap between management assurances and practice within the service. An action plan was submitted following concerns identified during the initial inspection; however, the follow-up visit found many of the same issues remained. This included concerns relating to repositioning, risk management, care planning, end-of-life care and governance arrangements. This demonstrated leaders had been unable to drive and sustain improvement.

Oversight of the service was poor. Management systems failed to identify missed care, inaccurate records, medication concerns, environmental issues and weaknesses in Mental Capacity Act processes. Audits either had not been completed or had failed to identify serious concerns affecting people's safety and wellbeing.

Leaders did not always provide clear accountability and direction. Required audits had not been completed, responsibilities within the management team were not always understood and systems intended to monitor quality were ineffective.

The manager was unable to evidence the actions they had told us they had completed as part of the action plan they provided to us.

Whilst staff spoke positively about supporting people and we observed caring interactions, leadership had failed to create an environment where staff were consistently enabled to deliver safe and effective care. Poor practice remained unaddressed, risks were not consistently managed and opportunities to learn from concerns were missed.

People did not feel they could speak up and that their voice would be heard.

Leaders had not created an open and transparent culture where concerns were consistently identified, escalated and acted upon. We found concerns regarding the effectiveness of systems used to encourage challenge, promote accountability and drive improvement.

We were not assured staff would report or raise concerns. Staff either did not recognise poor practice, did not escalate concerns effectively, or concerns raised had not resulted in appropriate action.

There was limited evidence concerns raised within the service resulted in learning or sustained improvement. Despite management being aware of issues identified during the assessment, many remained unresolved during each on site visit. This demonstrated a culture where challenge and feedback were not consistently listened to and no meaningful action taken.

Feedback gathered during the inspection also identified concerns regarding staff behaviour. One person reported experiencing a negative interaction with a staff member which had caused them distress. Whilst this was an isolated incident, it highlighted the importance of creating an environment where people feel confident concerns will be heard and addressed.

The provider did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Leaders could not demonstrate a strong culture of equality, diversity and inclusion for the workforce. Systems focused on operational compliance and service delivery, with limited evidence showing how leaders promoted inclusive working practices, staff wellbeing and a culture where all staff felt valued and supported.

Management oversight was weak and did not provide assurance staff were consistently supported to succeed in their roles. Leadership challenges within the management team had not been managed effectively, contributing to gaps in oversight, unclear responsibilities and inconsistent accountability.

Roles and responsibilities were not always clearly understood across the leadership team. For example, senior staff were unclear regarding responsibility for key audits and quality assurance processes. This created inconsistency in expectations and oversight and increased the risk of staff not receiving appropriate guidance and support.

Inspection findings indicated staff were often left working within systems containing poor care records, generic assessments and ineffective monitoring arrangements. Leaders had failed to create an environment where staff were consistently enabled to challenge poor practice, contribute to improvement and feel supported to deliver high-quality care.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance systems were ineffective and failed to identify, monitor and respond to significant risks across the service. Leaders did not have adequate oversight of safety, quality or performance, resulting in ongoing concerns affecting people's care and wellbeing.

Quality assurance processes failed to identify many of the issues found during this assessment. This included missed repositioning, medication concerns, incomplete and contradictory care records, poor risk management, inadequate Mental Capacity Act processes, environmental concerns and gaps in end-of-life planning. Concerns were identified by us rather than through the provider's own monitoring systems.

Audit systems lacked strong effective records. Required audits had not always been completed and, where audits had taken place, they failed to identify widespread issues affecting people's safety and quality of care. For example, governance systems failed to identify repeated gaps in repositioning records for people at risk of pressure damage, including people living with grade 3 and grade 4 pressure ulcers.

Management oversight was poor. Senior leaders were unable to demonstrate effective monitoring of care delivery, staff practice or compliance with policies and procedures. Responsibilities were not always clearly understood, resulting in key governance processes not being completed.

The provider failed to respond effectively to identified concerns. Following the first assessment onsite visit, an action plan was submitted outlining improvements. However, we found on our return visits that many of the same concerns remained. Care plans continued to be generic and contradictory, risk assessments remained poor, Mental Capacity Act documentation had not improved and concerns relating to repositioning and end-of-life planning remained unresolved. This demonstrated a failure to implement and sustain improvements.

Leaders could not always evidence actions reported as completed. Systems intended to drive learning and improvement were ineffective. Repeated falls, medication errors, pressure care concerns and incidents had not resulted in robust analysis, learning or sustainable action. Opportunities to improve outcomes and reduce future risks were repeatedly missed.

The provider had not demonstrated the skills to achieve sustainable improvement. Concerns identified were widespread, longstanding and remained despite management intervention. Governance systems failed to provide assurance risks were understood, monitored or effectively managed.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider did not always work effectively with partners and external agencies to ensure people received safe, coordinated and responsive care. Whilst evidence of involvement from healthcare professionals was present in some areas, systems were not effective in ensuring recommendations, decisions and actions were consistently followed through.

Communication with external professionals did not always result in improvements to care planning or risk management. We found examples where specialist advice relating to nutrition, pressure care and health needs had not been fully embedded into care records or monitoring systems, increasing the risk of inconsistent care.

Partnership working around decision-making was also weak. Records did not consistently demonstrate involvement from relevant professionals during significant decisions affecting people's care and treatment. This was particularly evident within best interest processes, where involvement from multidisciplinary professionals was often absent or poorly evidenced.

Opportunities to work collaboratively with families and representatives were not always maximised. Records contained examples where significant decisions regarding healthcare and treatment had been influenced by relatives without clear evidence supporting how these decisions had been managed or reviewed by the service.

Leaders were unable to demonstrate effective partnership working had driven improvements following concerns identified during inspection. Despite the involvement of healthcare professionals and management action plans, many issues remained unchanged at the follow-up visit, including concerns relating to care planning, risk management and end-of-life care.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider had failed to establish a culture of learning, improvement and innovation. Systems were ineffective in identifying concerns, learning from incidents and driving sustainable improvement across the service.

Repeated issues identified during the assessment had not been recognised through the provider's own governance processes. Significant concerns relating to repositioning, medication management, risk assessments, care planning, Mental Capacity Act documentation and end-of-life care had not been identified or addressed by leaders. This demonstrated a failure to learn from practice and proactively improve the quality of care provided.

The provider's response to concerns was ineffective. Following our first onsite visit, an action plan was submitted outlining improvements. However, a follow-up visit found many of the same concerns remained. Generic care plans, incomplete risk assessments, poor repositioning records and weak governance systems continued to be present despite management assurances improvements had been made.

Incidents, accidents and safety concerns were not consistently used as opportunities for learning. Repeated falls, medication errors, pressure care concerns and documentation issues had not resulted in robust reviews, clear action plans or measurable improvements in practice. Opportunities to identify trends and prevent recurrence were repeatedly missed.

Quality assurance systems did not promote continuous improvement. Audits were either not completed or failed to identify significant concerns occurring across the service. Where actions had been identified, there was limited oversight to ensure completion or evaluate impact.

There was little evidence of innovation or proactive service development. Leadership efforts were focused on responding to ongoing concerns rather than improving outcomes, enhancing people's experiences or developing new approaches to care.