Drumconner Lancing

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to governance at the service and of their registration conditions.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

There was a failure to demonstrate a positive culture that was focused on learning and improvement. Systems were not effective in managing risks, identifying shortfalls and making changes to improve the service. A staff member had told us, “A person might forget that they can't use stairs. I think it would be safer if they were downstairs.” There was a failure to ensure risks in the environment which had been identified by some staff had been fully assessed and managed. This did not provide assurance of the providers and registered managers understanding about how a culture based on transparency would support effective risk management. The provider and registered manager had not identified significant risks with people’s safety regarding staircases. Following feedback from CQC the provider took immediate action to consider the potential risks and took action to mitigate these in order to keep people safe.

The provider did not uphold people’s human rights; they failed to ensure staff were working within the principles of the Mental Capacity Act 2005 which meant the culture of the service was not person-centred.

Staff told us they reported any concerns to the registered manager who was in day-to-day charge of the service. Staff did not always demonstrate an understanding of their role with regard to safeguarding people. Staff did not always know what action they should take or how they should respond if, for example, if a person had an unexplained injury. This meant safeguarding events had not been consistently investigated and reported to external bodies to ensure openness and transparency.

The language used by staff in people’s care plans, was not always respectful and did not support people’s dignity. One person’s care plan had described the person as, “Confused and muddled” and “resistive” This did not support a culture of respect for people’s dignity.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

The provider and registered manager demonstrated a lack of knowledge in respect of regulations and responsibilities. Drumconner Lancing was registered to provide a service to a maximum of 60 people; at the time of our assessment, they were in breach of their conditions of registration and had accommodated 67 people. They did not ensure they led by example to promote an inclusive culture and failed to effectively assess the quality-of-care people were receiving. The provider failed to robustly assess people's needs, care records which were shared with staff were inadequate and did not equip staff to provide a high quality and safe service. The registered manager demonstrated a lack of knowledge by failing to understand, acknowledge and facilitate the important safety aspects of care delivery, such as the management of risk, effective and safe care planning and the specific training staff require to effectively carry out their role. Feedback from staff was positive on the approachability and support from the provider.

Although feedback from staff was positive, there was a lack of awareness, and concern, from staff on the absence of risk information and guidance around people’s health conditions including dementia and the risk of falls which left people at significant risk of harm.

People did not always feel they could speak up and that their voice would be heard.

Whilst staff spoke highly of the provider and the support they received; records of staff meetings failed to show how the provider invited staff to contribute, raise concerns or suggestions. Staff told us they could approach their line managers; however, we identified incidents where staff had not spoken up about people’s injuries which indicated they did not recognise the injuries were a concern or they were not always confident to speak up.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people and staff.

The provider had recruited a diverse workforce. Some, but not all staff, had completed training in equality and diversity. This increased the risk of people not always receiving support in line with current good practice guidance that valued peoples’ diverse needs.

Not all staff had received guidance or training to equip them to support people with a learning disability and autistic people. Leaders and staff did not have an awareness of ‘Right support, right care, right culture’ guidance, and this increased the risk of people not receiving support which was inclusive.

One staff member described being supported to progress in their role and described how they had completed training to support them with this goal. Staff told us they felt included and listened to. Their comments included, “If I have any ideas I go to the registered manager,” and “I can go to the registered manager, who will go above and beyond to help.”

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Management systems were not effective in identifying shortfalls in the quality and safety of the service. The provider’s systems had failed to identify multiple concerns identified at this inspection, such as the failure to assess, review and manage risks to people, including risks of falls in relation to staircases, and risks associated with people’s rights to refuse support and people’s well-being. The provider could not be sure risk assessment processes were robust, or staff possessed adequate skills to complete risk assessments which were in line with their policies and fully considered the individual and potential control measures.

Systems for monitoring the safety of the environment had not always identified risks, including the failure to assess and mitigate risks of falls on the stairs. Systems had not prioritised completion of actions which had been identified in the providers fire risk assessment, potentially placing people at increased risk of harm.

The registered manager did not always demonstrate good oversight of the service. Systems for auditing incidents and accidents were not effective. The registered manager could not be sure of any trends and themes in relation to incidents of injury affecting people. This meant they were not clear about the level of risk. The registered manager told us a number of people needed support to move with the use of a hoist and sling, and they had access to inhouse moving and handling trainers, however, systems had not identified or mitigated risks to people from concerns with moving and handling practices. Risk assessments and care plans failed to provide guidance for staff in how to do this safely and in the way the people preferred.

Systems to support the deployment of staff were not effective. The registered manager told us they assessed the personal care needs of people to determine how many staff were required and where they should be deployed across the service. This had not taken into account changes in people’s needs, including dementia, mental health or mobility. The registered manager told us people had been advised to call for staff support to come downstairs in the lift; however, the deployment of staff had not been revised to accommodate this requirement.

Following our assessment the registered manager told us they had appointed additional staff, “Their main role is to answer the bells that frees up the carers for other tasks.”

Audits of people’s support were not effective, we reviewed audit outcomes which concluded people were being supported in a person-centred manner, however, care plans lacked person-centred detail, and staff had not always supported people to maintain their dignity and privacy. Quality assurance systems did not identify where staff had recorded potential incidents of restrictive practices or where assessments of risk had insufficient detail.

The provider did not understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

Systems for monitoring incidents were not robust. Incidents of injury potentially related to staff moving and handling practices were not reported to the local authority or to CQC in line with safeguarding procedures. This did not support openness and transparency. The registered manager told us they audited incidents, however, was unaware when we showed them incidents of injuries which were reportable and agreed with our concerns, regarding the trends of injuries occurring when people were supported with moving and positioning. The registered manager told us they did not routinely share information with the local authority safeguarding team as they had not identified incidents of injury as safeguarding concerns.

Systems in operation had failed to ensure the service was always working collaboratively. For example, we have commented on shortfalls in staff dementia knowledge and how this potentially resulted in staff not always respecting people’s rights. Leaders had failed to identify the need to increase understanding or prioritise potential opportunities for learning designed to improve the quality of support people received. The registered manager told us they planned to engage with a dementia specialist for additional support.

Whilst our assessment identified significant shortfalls, visiting health care professionals provided positive feedback about their experience. Comments included, “I feel Drumconner Lancing is a really good home, I can see how different family run care homes are compared to a bigger company owned home, the fact the owners are so involved is very positive in my opinion. Many of the staff have been around for years, the staff are happy and know the residents well and the residents know the staff well.” And “I find Drumconner Lancing to be well run, the staff are very friendly, kind and professional, it is always maintained to a high standard, it is a pleasure to visit this nursing home."

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The registered manager failed to keep their knowledge up to date, we identified incidents where the registered manager was unaware of guidance and regulation, including the requirements of Data Protection regulations. The registered manager failed to demonstrate their understanding of appropriate information sharing which was not in line with GDPR. We requested their removal of sensitive staff employment information from CQC’s secure portal.

The provider’s systems failed to identify shortfalls and support learning to make improvements. Incident records were not always accurate and complete, there was a lack of analysis to identify patterns and trends and to learn from mistakes. There was limited understanding of how to fully assess and manage risks of falls for people and this potentially impacted people’s safety. Although risks for some people were apparent, the registered manager had not taken action to ensure risks were minimised. This did not demonstrate that there was learning from incidents.

The provider did not have effective quality monitoring systems in place to monitor staff practice which would have identified the need to ensure staff practice was in line with their training. The provider had failed to ensure staff had effective training to support people with complex needs including dementia and behaviours of concern which staff found difficult to manage.