Drovers Call

Updated 23 December 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 4 inspectors across 3 days and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Drovers Call is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Drovers Call is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 14 members of staff including the provider, registered manager, manager, deputy manager, clinical lead, training lead, care navigator, complex senior lead, activities coordinator, cook and carers.

We looked at around 30 people's care records in detail and records that related to how the service was managed including staffing, training, medicines and quality assurance. We spoke to 20 relatives and 4 people who use the service and used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 23 December 2023

About the service

Drovers Call is a 'care home'. It provides accommodation for older people including people living with dementia, providing personal and nursing care. The home can accommodate up to 60 people. At the time of our inspection there were 56 people living in the home. Accommodation is provided on three floors divided into five units.

People’s experience of using this service and what we found

Organisational governance and quality assurance systems had not been effective in monitoring and improving the quality and safety of the service. We found systemic failures with oversight and quality assurances processes, which posed significant risk to people.

There were indicators of a closed culture where chemical and physical restraint was disproportionately used. Staff had a lack of support or guidance on how to support people to lead inclusive and empowered lives.

The service failed to protect people from poor care and abuse. Staff had failed to identify, record and report incidents, additionally, the provider had failed to monitor the safety and quality of the service resulting in poor care and outcomes for people, with potential incidents of a safeguarding nature occurring.

Risk management was poor. A lack of support plans and assessments in place meant people's needs were not identified assessed or managed effectively. Ineffective care planning led to people experiencing increased periods of distress, restrictive practices and hospital admissions.

People did not always receive person centred care to meet their needs and preferences. Care files did not always have necessary support plans in place.

The service did not have enough staff, a high number of agency staff were used, significantly increasing the risk of inconsistent care.

People and their relatives provided mixed feedback, raising concerns with communication and staffing, but also highlighted they felt their relative received good care.

The service did not always follow or act in accordance with the Mental Capacity Act (MCA). The registered manager failed to apply for Deprivations of Liberty authorisations, meaning people were being deprived of their liberty without the legal authority and an infringement of their human rights.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 15 May 2021).

Why we inspected

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The inspection was prompted in part due to concerns received about the use of restrictive practices, mental capacity assessments, governance and leadership. A decision was made for us to inspect and examine those risks.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Drovers Call on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to risk management, restrictive practices, safeguarding, leadership and governance at this inspection and placed urgent conditions on the provider’s registration.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.