Danescourt

On this page

• 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 good. At this assessment the rating has changed to requires improvement.This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

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

This service scored 61 (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 had a shared vision, strategy, and culture based on transparency, equality, human rights, diversity, inclusion, and engagement with people and their communities.
However, this was not consistently reflected in practice. The provider had not considered whether their overarching policies were appropriate or proportionate to the needs of the service. For example, the decision not to train staff to support medicines administration in the community This resulted in restrictions within a registered care home setting, where people should be supported to access the community while safely receiving their medicines, limiting choice, independence, and person-centred care.
 

Leaders were visible, capable, and compassionate. Staff reported feeling supported by the registered manager and spoke positively about the management. However, as the registered manager worked within staffing numbers, their capacity to effectively monitor the service and maintain oversight was limited.
While the service benefited from consistent leadership, systems and processes were not robust enough to identify, manage, and mitigate risks. Oversight relied heavily on provider-level governance systems, which were not effective in assuring quality and safety. Governance arrangements required strengthening and embedding into practice to ensure quality, safety, and regulatory compliance were consistently assured.
 

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.
The provider had a speaking up and whistle blowing policy in place. Staff had received supervisions and told us they felt supported by management and felt comfortable with raising any concerns. Comments included, “The registered manager is very good and supportive.” And “I’m supported by the manager who is fantastic.”
 

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.
The service supported a diverse workforce, and there was no evidence that staff felt disadvantaged or unsupported.
During our onsite inspection, we observed a positive culture and feedback from staff was positive about being treated fairly at work.
 

Provider-level governance systems were not effective. We were provided with a small number of audits which reported high levels of compliance; however, these findings were not consistent with findings identified during the inspection. For example, both the community pharmacy audit and the care records audit indicated high or full compliance, yet neither had identified significant gaps in care planning, record-keeping, consent, or medicines management. Systems were not effective in identifying and addressing risks or areas for improvement.
The provider had also not identified that their medicines policy was not suitable for the service, resulting in a blanket restriction on people’s freedom in accessing medicines in the community.
We were concerned that effective service-level audits were not taking place, or had not been shared, which meant the registered manager could not demonstrate sufficient oversight of the service. While staff said the service was well managed and the registered manager understood their role and responsibilities, oversight relied heavily on provider-level governance systems. These systems did not provide accurate assurance of quality or safety and failed to identify or drive improvement in key areas.
 

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff and leaders worked well in partnership with others to support people’s care. They understood the importance of working collaboratively with external professionals and services to ensure care was joined up and met people’s needs. Information was shared with partners where needed, and staff were aware of how to access support from other agencies.

The service was part of the local community, and staff supported people to access community opportunities and activities to improve their outcomes and independence. Staff described positive relationships with partners and felt there was open and transparent collaboration with people, relatives, and other services.
 

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

Information requested during the inspection did not give full assurances that the provider's systems for monitoring quality and safety were effective. Governance systems were not effective in identifying issues or driving improvement, and the provider could not demonstrate that quality and safety were being consistently monitored or sustained.

Staff were supported to develop their skills in improvement and innovation, with opportunities for learning and progression. They were encouraged to share ideas and contribute to service development, and leaders promoted an open culture where staff felt able to speak up. There was a positive relationship between staff and leaders, with staff reporting trust and engagement. The service also maintained external partnerships to support improvement.