Danescourt

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 requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

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

This service scored 56 (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 always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

The service did not always have a proactive and positive culture of safety. Incidents and safeguarding concerns were not always identified or reported, and governance systems did not detect patterns or risks. As a result, the service could not be assured that learning was being shared with staff for opportunity for learning and improved practice. This increased the risk of action not being taken to promote people’s safety. For example, we identified an incident had occurred in the service and asked the provider to assure us it had been adequately recorded, reported and to ensure appropriate action had been taken. We raised this with the provider, who advised they would review care records and confirm when this had been completed. However, this confirmation was not provided following the assessment. As a result, we could not be assured that governance systems were effective in driving learning and continuous improvement.
 

The provider did not always work well with people to establish and maintain safe systems of care. Although people were supported to attend health appointments and healthcare professionals were involved in supporting some identified risks, care plans, risk assessments and records did not consistently contain sufficient information to demonstrate how risks relating to skin integrity, dementia, security and medicines were assessed, monitored and managed, or provide staff with clear guidance on how to support people safely.We discussed these concerns with the provider, who stated they would review each person’s care records and strengthen the information available.

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

People can only be deprived of their liberty to receive care and treatment when the correct legal processes are followed. We checked whether the service was working in line with the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS). DoLS applications had been submitted and records were in place; however, staff were unable to consistently locate them and did not demonstrate a clear understanding of the legal framework underpinning people’s care. Records relating to mental capacity, consent and decision-making were not consistently accessible. This placed people at risk of unlawful or inappropriate care and treatment, as staff could not be assured, they were acting in line with legal requirements or making decisions in people’s best interests. It also limited effective oversight and accountability, increasing the risk of rights not being upheld.
Staff reported receiving safeguarding training and demonstrated awareness, including raising concerns about people feeling unsafe.
 

Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
Risk assessments were not always person-centred or updated when people’s needs changed, and some lacked clear strategies for managing foreseeable risks. For example, care records were not always updated after incidents, and actions to reduce risks were not recorded. This meant staff did not always have the guidance they needed to provide safe, consistent care, increasing the risk of harm.
Care records did not consistently reflect current support needs, and some contained outdated or contradictory information. For example, care records did not include strategies for ensuring people were safely supported in the community or for self-administering medicines and risks were not assessed or monitored for skin creams that could become flammable if they built up on clothing or bedding. This increased the risk of unsafe or inconsistent care and limited people’s ability to be active partners in managing risks.
 

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

Environmental safety concerns were identified on the day of our assessment regarding hazardous substances which had not been securely stored and a fire exit which was obstructed. Additionally routine checks of equipment were not consistently being carried out to ensure equipment was safe. However other environmental checks for example water safety were taking place.
We raised concerns with the management team and immediate action was taken. However, improvements were required to ensure all environmental and equipment checks were robust, consistently completed, and effective in identifying potential risks.
 

The provider ensured there were enough suitably qualified, skilled, and experienced staff who worked well together to meet people’s needs. Staff were safely recruited, completed an induction, and were matched to the service based on their skills and suitability.
There were sufficient staff to support people, including when 1:1 support was required in the community, and rotas were planned to ensure appropriate staffing levels for activities.
 

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.
The service was clean and homely. Staff supported people to be involved in cleaning and doing their own laundry to improve their living skills.
 

The provider did not consistently ensure medicines and treatments were safe or tailored to people’s needs, capacity, and preferences.

Nurses were trained and competency assessed to administer medicines but did not routinely support people in the community. Support staff who provided community support were not trained or competency assessed to administer medicines. This restricted people’s ability to access activities outside the service and created risks where timely access to medicines was important, such as for conditions like angina or asthma.
For example, one person was prescribed antibiotics four times a day, requiring them to return to the care home for each dose, which limited their independence and choice.
Medicines management was inconsistent. PRN protocols were not always in place, and where they were, they lacked clear guidance on dosage intervals and maximum doses. Time-sensitive medicines were not always administered as prescribed; for example, there was no evidence a medicine required before food had been given correctly.
Records and practice for creams were inconsistent. For example, one person required cream applying to their legs. One plan stated application to the legs only, while another stated apply all over the body. People considered to be self-administering medication did not have individual risk assessments in place to support this decision, while staff were completing MAR charts as though they had administered medicines. This created a risk of unsafe and inconsistent medication practices, as there was no clear oversight of how medicines were being managed. It also meant records did not accurately reflect who was responsible for administration, increasing the risk of errors, potential harm to people, and a lack of accountability. Topical and flammable creams were stored in bedrooms without documented risk assessments.
Audits carried out had not identified the issues we found and were therefore ineffective. Records and practice did not demonstrate safe, consistent, or person-centred medicines management, and internal systems had failed to identify these concerns. Temperature checks were completed consistently.