Danesford Grange Care Home

Care plans, risk assessments and daily records were frequently generic, contradictory and not reflective of people's current needs, resulting in a lack of person-centred care and increasing the risk of unsafe care delivery. Staff could not always rely on records to understand how people should be supported safely.

The provider failed to demonstrate compliance with the Mental Capacity Act 2005, with capacity assessments and best interest decisions found to be incomplete, inconsistent, poorly evidenced or not in place. There was limited evidence decisions were being made lawfully or in people's best interests.

Significant concerns were identified regarding pressure care and repositioning, including missed repositioning times, gaps in records, inaccurate documentation and a lack of effective oversight. People at high risk of skin breakdown were exposed to avoidable risks of harm.

Medicines management was not sufficient. Medication errors, poor recording practices, unclear protocols and inadequate monitoring raised concerns about the service's ability to ensure medicines were administered safely.

Risks relating to falls, choking, nutrition, hydration, absconding and changing healthcare needs were not always effectively assessed, reviewed or mitigated. Incidents and accidents were not consistently analysed to identify learning or prevent recurrence.

Governance arrangements were ineffective. Audits had failed to identify many of the concerns we found during this assessment and management oversight was weak. During this assessment the registered manager was asked to produce an action plan to demonstrate the action they had taken to mitigate the significant risks found on inspection. A follow-up visit found many of the same issues remained despite assurances from the registered manager improvements had been made, demonstrating a failure to embed sustainable change.

Although inspectors observed caring interactions between staff and people using the service, these positive observations were significantly outweighed by the seriousness and scale of the concerns identified.

We have identified Danesford Grange Care Home to be in breach of regulations. These are, person centred care, need for consent, safe care and treatment, and governance.

In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

Peoples Experience

Whilst people and their relatives were positive about the care provided and consistently described staff as kind, caring, respectful and attentive, this did not reflect our findings around the overall safety and care being delivered at Danesford Grange Care Home.

People told us they felt safe living at the home and were confident staff would respond if they needed support. Most people reported call bells were answered promptly, although some felt response times were longer during staff handovers or at particularly busy periods.

People spoke positively about the relationships they had developed with staff and said they were treated with dignity and respect. Individuals told us they were supported to make choices about their daily routines, including when to get up, go to bed, what to wear and whether to participate in activities. People's preferences, including requests for same-gender carers, were generally understood and respected.

Feedback about food was largely positive, with people describing meals as home-cooked, well-presented and with choices available. However, some people felt menus could offer greater variety and staff could provide more opportunities for residents to influence meal options. Several people also expressed a wish for increased activity choices, outings and more formal opportunities to share their views, such as resident or relative meetings.

People and relatives were complimentary about the caring approach of staff across all roles within the home. Staff were described as friendly, approachable and committed to supporting people's wellbeing. While most feedback regarding management was neutral or positive, several people and relatives reported limited interaction with the registered manager and felt management visibility could be improved.