CQC report explained · a residential care home
What the CQC found at Daneswood Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, detailed risk assessments, safeguarding systems and safe medicines arrangements. However, instructions for some medicines given using specialised techniques were not always complete, and some areas of the building needed refurbishment.
- Effective?
- Good
- No separate rating was given for Effective in this inspection report.
- Caring?
- Good
- No separate rating was given for Caring, although inspectors reported that people received kind and compassionate care and that staff respected their privacy and dignity.
- Responsive?
- Good
- No separate rating was given for Responsive. Inspectors found that people were supported with their interests, individual needs, choices and periods of distress.
- Well-led?
- Good
- The home had a positive, person-centred culture, clear management arrangements and quality checks covering areas such as care plans, medicines and infection control.
What inspectors found, May 2023
Daneswood Care Home was rated Good; inspectors found safe, kind and person-centred care, with some medicines information and building maintenance still needing attention.
This was an unannounced inspection on 27 and 28 April 2023. One inspector, a medicines specialist and an Expert by Experience took part. They spoke with relatives, staff and other professionals, observed people and staff, and checked care, medicines, recruitment and management records.
The home was rated Good overall. Safe and Well-led were both rated Good. Inspectors found enough staff, suitable risk assessments, safe medicines systems, safeguarding arrangements and effective checks on care quality. People were described as receiving kind, compassionate and person-centred support.
There were some areas to improve. Information for medicines given using specialised techniques was not always complete. Some parts of the building were deteriorating, which could affect cleaning. Inspectors also found gaps in the employment histories of two staff members, which the manager said would be addressed.
The previous rating, published in November 2019, was Requires Improvement. Safe and Well-led had both improved to Good. The provider had also acted on the earlier recommendation about medicines management.
Kind and dignified care
Inspectors found that staff understood people's individual needs and protected their privacy and dignity.
“People received kind and compassionate care. Staff protected and respected people's privacy and dignity.” from the report
Personalised support
People were supported to pursue their interests, make choices and take positive risks where appropriate. Staff had plans to guide them when they became anxious or distressed.
“People received person centred care and support.” from the report
Improved staffing
Inspectors found enough staff to meet people's needs. Relatives and staff said staffing had improved and familiar staff were supporting people.
“There were enough staff available to meet people's needs.” from the report
Learning from incidents
Incidents were recorded, reviewed for patterns and used to identify learning or actions for staff.
“Incidents were reviewed for themes and trends to determine any learning or actions for staff.” from the report
Better medicines management
The provider had improved its medicines systems since the previous inspection, including storage, staff training and checks on staff competence.
“At this inspection we found improvements had been made.” from the report
Incomplete specialised-medicine instructions
needs fixingInformation about how some medicines using specialised techniques should be given was not always complete. This was discussed with the manager, who said it would be addressed.
“Where people had their medicines using specialised techniques the information present did not always give complete information about how these medicines were to be administered.” from the report
Some areas need refurbishment
minorSome parts of the home showed deterioration. The provider had a refurbishment plan and inspectors saw progress, but the condition could affect how effectively those areas could be cleaned.
“Some areas of the service were showing signs of deterioration, which could impact on the effectiveness of cleaning these areas.” from the report
Employment history gaps
minorTwo staff records had gaps in employment history. The manager told inspectors this would be addressed.
“We identified 2 staff members who had gaps in their employment history, we discussed this with the registered manager who told us they would address this.” from the report
- 01How have you completed the instructions for medicines given using specialised techniques?
- 02What is the timetable for refurbishing the areas showing deterioration, and what has been completed so far?
- 03How do you check that all new staff have complete employment histories and suitable recruitment checks?
- 04How are the three areas of the home organised to make sure people are compatible and receive person-centred support?
- 05How do you support people during periods of anxiety or distress while keeping restrictions to a minimum?
This was an unannounced focused inspection of Safe and Well-led; no separate ratings were given for Effective, Caring or Responsive in this report. This explanation was written from the published report of 26 May 2023 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, December 2019
Rated Requires Improvement; inspectors found kind, personalised care but serious medicines and management checks needed improvement.
Inspectors visited the home unannounced on 30 September and 2 October 2019. They observed care, spoke with managers, staff and relatives, and checked care records, medicines, staff files, audits and environmental information.
The home was rated Good for Effective, Caring and Responsive. Staff were described as kind and caring, people had personalised care plans, and there were enough staff during the inspection to support activities and people's needs.
Safe and Well-led were rated Requires Improvement. Medicines were not always managed safely, some records were incomplete, and checks had not identified all the problems. An annual water safety test had also been missed, although this was arranged during the inspection.
The overall rating fell from Good at the previous inspection to Requires Improvement. The report says the management acted on some concerns during and after the inspection, but further improvement was needed.
Kind and respectful staff
People appeared comfortable with staff. Staff knew people well and supported privacy, dignity and independence.
“People were supported by kind, caring and patient staff.” from the report
Enough staff
Inspectors found staffing levels supported people's safety, needs and participation in activities during the visit.
“People were supported by enough staff to keep them safe and meet their needs.” from the report
Personalised care
Care plans reflected people's individual needs and wishes. Staff understood people's health conditions and preferences.
“People's care plans were personalised to their individual needs and wishes.” from the report
Activities and relationships
People took part in activities suited to their interests and sensory needs. The home also supported contact with important relatives.
“People participated in a wide range of activities to meet their needs and interests.” from the report
Medicines were not consistently safe
seriousMedicines hidden in food or drink did not always have the required checks. Stock discrepancies, unclear dose instructions and incomplete records created a risk of a missed or incorrect dose.
“People were at risk of incorrect dose being administered or a missed dose because medicine administration records (MAR) were not always completed in line with current best practice.” from the report
Management checks missed problems
needs fixingQuality systems had not identified the full range of medicines concerns or the missed annual water safety test. The provider was asked to improve its medicines practice.
“However, systems had not identified the range of concerns with medicine management.” from the report
Some choices were limited
needs fixingPeople did not always choose what they ate or when they ate. The home's location also limited access to the community.
“People did not always have choice in the food they ate or at what times meals were served.” from the report
Missed water safety test
needs fixingAn annual test had not been completed to check the water for legionella bacteria. The manager arranged the test during the inspection, and the provider later said the results were clear.
“However, an annual water test had not occurred to ensure water did not contain legionnaires bacteria in it.” from the report
- 01What changes have been made to medicines hidden in food or drink, and how are prescriber, pharmacist and least-restrictive checks recorded?
- 02How do you check that medicine stock, doses, allergies and administration records are accurate every day?
- 03What quality checks are now in place to make sure medicines and water safety tests are not missed?
- 04How will my relative choose what and when to eat, particularly if they have a specialist diet?
- 05How will you support my relative to access the community despite the home's location and staffing needs?
This was an unannounced comprehensive inspection covering all five CQC questions; Safe and Well-led fell to Requires Improvement while the other three ratings remained Good. This explanation was written from the published report of 3 December 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.
Every inspection of Daneswood Care Home
3 rated inspections over 6 years: the service has held its Good rating throughout.
- May 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- December 2019Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- May 2012
Report published without a new overall rating.
- May 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 8 November 2010.
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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