Shropshire care home rated inadequate as CQC begins regulatory action

A Shropshire care home has been downgraded from good to inadequate after inspectors identified concerns including medication errors, repeated falls, pressure care and whether restrictions placed on residents were being used appropriately.

The Care Quality Commission inspected Danesford Grange Care Home in June and found four breaches of regulations covering person-centred care, consent, safe care and treatment, and governance. The home is run by MGC Care Limited and provides accommodation for people requiring nursing care, including older people and those living with dementia.

Following the inspection, the overall rating fell from good to inadequate. Safety, effectiveness and responsiveness were also downgraded from good to inadequate, while leadership fell from requires improvement to inadequate. Caring declined from good to requires improvement.

The CQC has now begun the process of taking regulatory action against the provider. MGC Care Limited has the right to appeal that action.

Record keeping was a significant concern throughout the inspection. The CQC found important information was not always accurate or kept up to date, while some care plans were generic or contained conflicting information. Inspectors said this meant care was not always sufficiently tailored to the individual needs of residents.

Medication records also contained errors which resulted in incorrect or missed doses, creating concerns about the potential for people to receive too much or too little medication. Inspectors additionally identified problems with the recording and management of incidents, including falls.

In one case, a resident experienced 11 falls within a single month. The CQC found incidents were not always recorded and, when they were, they did not consistently lead to meaningful reviews or changes intended to prevent similar incidents happening again.

Inspectors raised significant concerns about pressure care and the repositioning of residents, identifying missed repositioning times, gaps and inaccuracies in records and insufficient oversight. Problems were also found in the support provided to some people with specialist nutritional requirements, including prescribed supplements not always being recorded, preferred dietary options not always being provided and insufficient detail in records monitoring food intake.

The inspection also raised concerns about whether people’s rights were being properly protected. The service was unable to demonstrate consistent compliance with the Mental Capacity Act 2005, with some capacity assessments and best-interest decisions incomplete, inconsistent, poorly evidenced or absent.

Restrictions including bed rails and coded access to doors were being used without clear evidence of the decision-making behind them or that less restrictive alternatives had been properly considered.

The physical environment presented further concerns. The service could not demonstrate that equipment and the home were being consistently cleaned, creating a potential infection risk. Inspectors also identified damaged flooring, broken thermometers in bathrooms, clutter and other maintenance issues which could present risks to residents.

Amanda Lyndon, CQC deputy director of adult social care in the Midlands, said inspectors had found a service that was not providing the expected standard of care and was putting people at risk. She highlighted poor record keeping as a recurring problem and said people using care services should be able to expect safe, effective and high-quality support that meets their individual needs.

The findings represent a substantial deterioration since Danesford Grange’s previous rating, with four of the five areas assessed now rated inadequate and caring rated requires improvement.

The CQC said taking action against a provider was a last resort, but it has now started the regulatory process following the concerns identified during the inspection. The provider retains the right to appeal.

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