CQC report explained · a nursing home
What the CQC found at Danesford Grange Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found suitable staffing, safeguarding procedures, risk assessments and medicines processes. They also found that accidents were reviewed and used to improve care.
- Effective?
- Good
- People's care was planned around their needs and choices. Staff supported nutrition, health appointments and decisions under the Mental Capacity Act.
- Caring?
- Good
- Staff treated people with kindness, compassion, dignity and respect. People were involved in decisions where possible, with relatives or advocates involved when needed.
- Responsive?
- Good
- Care was personalised to people's preferences, communication needs and cultural or religious choices. Activities and end-of-life support were available, although one complaint record did not clearly show its outcome.
- Well-led?
- Requires improvement
- Quality monitoring had improved and staff spoke positively about the management team. However, there was no CQC-registered manager at the inspection, and some supervision records had not been completed.
What inspectors found, January 2019
Rated Good overall, but inspectors rated well-led Requires Improvement because management records and registration arrangements were not fully in place.
This was an unannounced planned inspection on 11 December 2018. Inspectors spoke with people living in the home, a relative and staff. They also reviewed care records, staff files, policies and management records, and observed care.
The home was rated Good for Safe, Effective, Caring and Responsive. Inspectors found people were safe, received their medicines on time, had their health and dietary needs supported, and were treated with kindness, dignity and respect.
The home was rated Requires Improvement for Well-led. The manager was not registered with the CQC, and some supervision and training records were not up to date. A complaint record also did not show the outcome clearly.
The overall rating improved from Requires Improvement at the previous inspection. The three earlier breaches had been put right and the report says the relevant regulations were now met.
Safe care and staffing
Inspectors found enough suitable staff to meet people's needs. Risk assessments, safeguarding arrangements and fire safety checks were in place.
“The service ensured there were sufficient numbers of suitable staff to support people to stay safe and meet their needs by regularly assessing people's dependency.” from the report
Kind and respectful staff
People were treated with kindness and compassion. Staff respected privacy, dignity and individual preferences.
“We saw people were treated with kindness, respect, and compassion.” from the report
Personalised support
Care plans reflected people's needs, preferences and aspirations. The home supported religious, cultural and communication needs.
“People had choice and control over the way their care was planned.” from the report
Improved quality monitoring
The systems used to check care quality had improved substantially since the previous inspection. Inspectors found stronger oversight of the home.
“Systems and processes to assess and monitor the quality of the provision were improved and robustly in place.” from the report
End-of-life care
The home had achieved accreditation for end-of-life care and planned proactively with people and health professionals.
“This meant that people benefitted from pro-active planning and staff working closely with GPs in the final stage of their life.” from the report
Manager registration
needs fixingThere was no manager registered with the CQC when inspectors visited. The provider said an application would be submitted within four weeks.
“The provider did not have a manager registered with the commission.” from the report
Incomplete staff records
needs fixingRecords of some staff supervision and recent training events had lapsed or had not been documented. The provider agreed to update them.
“We found some supervisions had not been documented in supervision records by the manager which the provider agreed to address.” from the report
Complaint outcome not recorded
minorOne complaint had led to a staff meeting, but the complaint log had not been updated with the outcome.
“However, this 'outcome' had not been updated within the complaint log by the manager.” from the report
- 01Has the manager's CQC registration application been submitted and completed?
- 02Are staff supervision, training and meeting records now fully up to date?
- 03How are complaints recorded, investigated and closed, including the outcome?
- 04How does the home check that the improved quality monitoring systems continue to work?
- 05How are people's individual care plans and risk assessments reviewed when their needs change?
This was a planned inspection covering all five key questions, with Safe, Effective, Responsive and Well-led specifically checked against concerns found at the previous inspection. This explanation was written from the published report of 9 January 2019 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, June 2018
Rated Requires Improvement; inspectors found caring staff and some improvements, but serious safety and management problems remained.
This was an unannounced comprehensive inspection on 26 April 2018, followed by an announced visit on 30 April. Inspectors spoke with people living at the home, relatives, staff and other professionals. They also reviewed records, observed care and inspected the building.
The home was rated Requires Improvement overall. Caring was rated Good. Safe, Effective and Responsive were rated Requires Improvement. Well-led was rated Inadequate.
Inspectors found enough staff, kind and respectful care, reliable medicines support, enjoyable activities and support at the end of life. However, building work had created fire and injury risks. Infection control, care records, mental capacity records and quality checks were not reliable enough.
Three regulations were breached. The provider was required to improve safe care and treatment, good governance and the display of the previous rating. A warning notice was issued about good governance.
Kind and respectful care
Inspectors saw staff taking time to understand people, offer choices and support them when distressed. People were treated as individuals.
“People were treated with dignity and respect by those supporting them.” from the report
Enough staff
People said staff were available when needed. Inspectors saw staff supporting care and activities promptly.
“People were supported by enough staff to meet their needs safely and in a way they preferred.” from the report
Medicines support
People received medicines as prescribed from trained staff. Records for 'when required' medicines were accurate and medicines were stored appropriately.
“People received their medicines as prescribed by trained and competent staff members.” from the report
Activities and social contact
People were offered activities such as films, quizzes, bingo and outings. Staff also spent time with people who did not want to join organised activities.
“People had the option to be engaged in a range of activities that they found stimulating, enjoyable and fun.” from the report
End-of-life wishes
People's spiritual and emotional wishes were recorded. Families could stay with their relative, and care was planned around personal preferences.
“People were cared for at the end of life by staff members who knew their individual preferences and supported their personal wishes.” from the report
Fire and building risks
seriousBuilding work had made some fire detection systems unusable, weakened fire barriers and obstructed exits. Inspectors also found other hazards, including exposed hot pipes, unsecured items and building materials accessible to residents.
“The provider did not assess or properly manage environmental risks.” from the report
Poor maintenance and infection control
seriousRepairs were not completed promptly. Inspectors found damaged surfaces and fixtures that could not be cleaned effectively, as well as dust and materials that created infection control concerns.
“Maintenance tasks were not effectively completed and infection prevention and control measures had not been imbedded into staff or managerial practice and oversight.” from the report
Unclear care records
needs fixingSome care plans and risk assessments gave conflicting instructions. This could lead to staff supporting someone in a way that did not match their needs or abilities.
“Some of the care and support plans had conflicting and confusing information.” from the report
Mental capacity records
seriousSome records did not clearly show whether a person could make a particular decision. One application relating to a person's liberty had not been made when inspectors raised the issue.
“The lack of managerial oversight regarding people's capacity assessments and DoLS applications put people at risk of having their rights violated.” from the report
Weak quality checks
seriousManagement checks failed to find important safety, infection control and care record problems. Incidents and accidents were not routinely reviewed in enough detail.
“The provider did not have effective quality monitoring processes in place to identify improvements and to drive the quality of care provided.” from the report
Previous rating not displayed
minorThe home's previous CQC rating was not displayed as required at the premises or on its website. The provider supplied evidence that this was corrected after the inspection.
“Danesford Grange was not displaying its last previously rated inspection conspicuously at its main place of business.” from the report
- 01Have all the fire safety problems caused by the building work been fully corrected, and has a current fire risk assessment been completed?
- 02Which repairs and infection control actions identified during the inspection are still outstanding?
- 03How do you make sure care plans and mobility instructions are consistent and reflect each person's current needs?
- 04How are mental capacity assessments and applications relating to restrictions on liberty now checked and kept up to date?
- 05What changes have been made to quality audits and management reviews since the warning notice?
This was an unannounced comprehensive inspection of the home, with a further announced visit, covering all five key questions and the building and care provided. This explanation was written from the published report of 19 June 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Danesford Grange Care Home
3 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- January 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- March 2017Requires improvementSafe: GoodEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2015
Registered with the Care Quality Commission on 19 October 2015.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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