Danescourt

We completed a comprehensive assessment due to the time elapsed since the previous inspection, where the service was rated Good. Following this assessment, the overall rating changed to Requires Improvement. We identified 3 breaches of regulation relating to consent, good governance, and safe care and treatment.

We assessed the service against the principles of Right Support, Right Care, Right Culture. The provider could not demonstrate these were consistently met in practice.
Improvements were required to ensure records, risk management systems, medicines processes and oversight arrangements were robust, accurate and reflective of people’s current needs. Care records and risk assessments, although reviewed, lacked sufficient detail to guide staff in meeting assessed needs.

Records relating to legal frameworks and restrictions did not consistently provide clear guidance. Staff were not trained to administer medicines when people were out in the community, which meant people could not always access medicines in a flexible and person-centred way. This created restrictions on how people accessed activities and increased the risk of unmet health needs.
Records did not consistently demonstrate that risks had been fully assessed, escalated, monitored or shared with relevant professionals where required. Medicines processes required strengthening to ensure safe, person-centred care, including clearer protocols, accurate recording and improved oversight.

Records did not demonstrate people had consented to care or, where capacity was in doubt, there were not always records available to demonstrate assessments of capacity had been completed. Staff told us, and records indicated, some people may lack capacity. Information relating to Deprivation of Liberty Safeguards (DoLS) was not consistently recorded within care records or readily accessible to staff, and care records did not always include current or specific guidance needed to ensure people were supported safely and in line with any conditions or restrictions.
Environmental risks were identified on the first day of inspection, including unsafe storage of hazardous substances and an obstructed fire exit. These were addressed promptly; however, they highlighted the need for improvements to routine safety checks and oversight arrangements.

People were supported to maintain their hobbies and interests; however, arrangements for medicines administration reduced flexibility and could impact people's ability to access the community independently. Care records did not always include sufficient detail about people’s health needs. Oversight by the registered manager and provider governance systems had not consistently identified or addressed the concerns found during this assessment and required strengthening. Information requested during the assessment was not always readily available at the time it was requested, which limited timely assurance regarding some areas of risk, quality and governance. Improvements were made in response to concerns raised during the inspection; however, further action was required to address all areas identified.

People were involved in their care, including choosing their food and drink and taking part in developing life skills. People told us staff were kind and caring and that they felt safe.
Staff worked with other professionals to support positive outcomes and smooth transitions between services.

We requested an action plan from the provider in response to the concerns identified.