Drovers House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 59 (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 always have a proactive and positive culture of safety. Staff did not always listen to concerns about safety. Lessons were not always learnt to continually identify and embed good practice.

The provider did not have effective systems to ensure concerns and incidents were consistently reviewed and used to drive improvement. Learning from accidents and incidents was not always completed in a way that identified underlying causes or informed actions to mitigate risks. When risks were identified, people’s care records were not consistently updated to guide staff on how to support people safely. We saw examples where people had fallen, experienced weight loss or developed skin damage, yet the information recorded did not contribute to wider learning or proactive planning to prevent recurrence.

Where lessons had been identified, these were often shared informally between staff. Records and supporting evidence did not demonstrate a structured approach to reviewing incidents, implementing changes or monitoring whether actions had been effective. This limited the provider’s ability to ensure learning was captured, embedded and sustained across the service.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care.

The provider did not consistently maintain accurate or complete care records. As information was not always updated or reflective of people’s current needs, we could not be assured staff or external professionals had access to reliable information to support safe care or mitigate risks. In several cases, records lacked up‑to‑date detail about risks such as falls, skin integrity or unplanned weight loss. This meant staff and external professionals may not always have had accurate information, increasing the risk of unsafe or inconsistent care.

When people moved between services, systems were in place to share information about their health needs, medicines and preferences for future care. However, the inconsistent quality of record keeping meant we could not be confident the information shared was always accurate or sufficient to support safe transitions. This created a risk that professionals taking over people’s care might not have the detail they needed to keep people safe.

Despite these concerns, we received positive feedback about staff involvement during people’s transitions between services. This included staff accompanying people to hospital in an emergency and for routine appointments, when their usual support network was unavailable.

The provider demonstrated strengths in ensuring continuity of care when people were discharged to Drovers House from hospital or moved into the home from the community. The registered manager completed face‑to‑face assessments before admission to ensure the service could safely meet people’s needs.

The home supported several people through a discharge‑to‑assess pathway. Staff worked closely with hospital teams and a range of healthcare professionals to ensure people moved into the home safely and received the support they required. One person told us staff were helping them regain independence ahead of their planned return home.

Staff contacted external healthcare professionals promptly when additional assessment or support was needed. However, the lack of consistently accurate records meant there remained a risk that important information could be missed or not communicated effectively.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe living at Drovers House and if they had any concerns, they were confident talking to staff. One person told us, “I’m safe here. I’ve never had any bother whatsoever since I’ve been here. If I was ever worried or concerned about anything I would talk to the staff.” Another person said, “I feel safe because the carers look after me.”

Staff received regular safeguarding training and were able to clearly describe different types of abuse, what signs they would look for, and the actions they would take to keep people safe.

Information about safeguarding and how to report concerns was visible around the home, helping ensure staff and visitors knew how to raise issues.

The registered manager understood their responsibilities for reporting safeguarding concerns to the local authority and to us. They demonstrated a good knowledge of safeguarding processes and had effective systems in place to ensure concerns were recognised, reported and acted upon promptly.

When receiving care and treatment, people can only be deprived of their liberty with the appropriate legal authority. In care homes, this can be done through a procedure called The Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act (MCA) 2005. We checked how the provider managed DoLS within the home. Where people had restrictions placed on their liberty, this was reflected in their care plan. For example, where a person had been assessed as lacking capacity to consent to care, the provider had ensured DoLS applications had been submitted to the relevant supervisory body.

The provider did not work well with people to understand and manage risks. Staff did not have the information they needed to provide individualised safe care.

Care plans did not consistently identify risks to people or provide clear guidance for staff on how to support people to manage those risks safely. People’s care records lacked accuracy, information and meaningful reviews, which meant staff did not have the information required to deliver safe and effective care.

One person had experienced 9 falls in 6 months, including a hospital admission following a head injury. Although their risk assessment had been reviewed and indicated they were at very high risk,this was not reflected in their care plan. The plan did not guide staff on how to reduce the likelihood of further falls or what proactive measures should be taken. Accident forms had been signed off by both the registered manager and senior managers on behalf of the provider, but these reviews did not analyse trends, ongoing risks or the effectiveness of the information available to staff. Despite numerous falls, the person’s care plan had not been reviewed.

Another person, also known to be at high risk of falling, had experienced 3 falls in the previous month. Their mobility care plan had not been updated since their admission in April 2026 and contained conflicting information about their mobility needs. The plan stated the person could mobilise independently, required assistance from 1 carer, required assistance from 2 carers, and needed a wheelchair. This inconsistency meant staff did not have reliable guidance to support the person safely.

A speech and language therapist (SALT) had assessed a third person who required a modified diet and thickened fluids, to reduce their risk of choking. The person’s nutrition care plan recorded they required a level 6 (soft and bite sized diet) but could also be given a level 5 (minced and moist) or level 4 (pureed) depending on how they were on the day. There was no clear rationale for when or why staff should offer alternative consistencies. The person’s care plan also failed to include information shared with us, about how their drinks should be served or when they needed supervision eating. In addition, there was no information available to staff about foods to be avoided, despite the person being at known risk of choking. Meal charts completed by staff indicated the person had been given meals not prepared to the correct consistency and foods not suitable for their recommended diet.

The provider’s electronic care records showed a fourth person was at risk of malnutrition. Weight records reflected the person had lost 14% of their body weight in the 6 months prior to our inspection. Their risk assessment had not been updated and incorrectly informed staff the person was at low risk of malnutrition. This was not accurate and did not give staff the information required to prevent and mitigate further weight loss.

The provider’s failure to ensure care plans were accurate, consistent, and reflected people’s current needs, placed people at ongoing and avoidable risk of harm.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider ensured essential environmental safety checks were completed in line with legal and regulatory requirements. These included checks relating to gas, electricity, water systems, Legionella, and equipment safety. Records showed routine on site checks were carried out regularly, and a dedicated maintenance team had oversight of most works required within the home. External contractors had also completed the necessary statutory safety checks.

During the inspection, we identified water running from the hot taps in some communal toilets was cool. Provider checks did not include the requirement to monitor the running hot water temperatures in these areas. Following our feedback, the provider assured us they would review and amend their processes to ensure these checks were incorporated alongside other water temperature monitoring within the home.

Staff were knowledgeable about what to do in the event of a fire and had received appropriate fire safety training. Regular fire drills helped ensure this training was embedded in practice. Personal Emergency Evacuation Plans (PEEPs) were in place for everyone living in the home. However, changes in occupancy in the 3 days prior to our inspection had not yet been reflected in the evacuation plans. The registered manager acknowledged this and confirmed they would implement processes to ensure PEEPs were updated promptly whenever changes occurred, so records remained accurate and up to date.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People told us staff were attentive and responded when they needed support. One person said, "They're very professional.” Another commented, "The staff seem happy here, they deal with everything that needs to be done." People consistently told us staff were available and that they received the care they required.

The provider had assessed the staffing levels needed to meet the needs of people using the service. Staff rotas were planned to ensure an appropriate skill mix across the home, and staff raised no concerns about staffing levels or their ability to deliver the care outlined in people’s care plans. The provider also had contracted staff available to cover planned and unplanned absences, such as annual leave or sickness. This meant people were supported by staff who were already familiar with the organisation’s systems, processes and expectations, helping to maintain consistency and continuity of care.

New staff received a structured induction when they joined the service, which included working alongside experienced colleagues and completing the Care Certificate. The provider required staff to refresh their training regularly to ensure they maintained the skills and knowledge needed for their roles and continued to work in line with best practice.

Staff were recruited safely in line with the provider’s policy and procedures. This included obtaining Disclosure and Barring Service (DBS) checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and their relatives told us the home was clean, and they had no concerns about hygiene. During our visit we identified minor issues where infection prevention and control (IPC) practice could be strengthened, including continence products not being appropriately stored and damaged waste bins in communal areas. Immediate action was taken to address these shortfalls.

Staff had completed IPC training and understood the importance of safe practice. One staff member told us, “We learn about the importance of keeping everything clean and wearing our gloves when doing personal care. It keeps infections away and keeps everyone safe.”

However, some staff did not work in line with the provider’s ‘bare below elbows’ policy and procedure, and the provider’s IPC and dress code and uniform policy did not inform staff of the provider’s expectations regarding working with uncovered facial piercings. The registered manager told us, “This had never been raised before.” They gave us assurances this would be reviewed and addressed.

There were sufficient domestic staff on duty, and most areas of the home were well maintained. Some kitchenette areas required more regular and detailed cleaning. The registered manager demonstrated they had already planned to allocate this responsibility to identified staff.

IPC audits were completed every three months by an IPC champion and were effective in identifying some shortfalls. However, the audit tool did not require the auditor to record target completion dates or how the completion of actions would be monitored. The provider agreed to strengthen this process to ensure timely follow‑up of any actions.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

Medicines were not consistently managed safely. While people’s medicines were ordered, administered and disposed of, by trained staff, who were trained and assessed as competent to do so, we found gaps in storage and risk management which increased the risk of harm.

We found numerous people were prescribed creams containing flammable ingredients. A safety alert issued by the National Patient Safety Agency provided a warning about the increased risk of severe and or fatal burns associated with the use of these types of creams and advised of actions for mitigating the risks. The provider’s medicines policy informed staff to advise people accordingly, but it did not address how risks should be managed for people who lacked capacity to understand or retain this information.

We also found that topical medicines were not always stored securely. Although tablet medicines were kept in locked cupboards, some prescribed creams and emollients had been placed on top of medicine cabinets in people’s rooms, making them easily accessible. This presented a risk of accidental ingestion particularly for people living with dementia.Best practice guidance recommends, where creams are stored in people’s rooms, an appropriate risk assessment should be in place. At the time of our inspection risk assessments had not been completed. This meant the provider had not taken reasonable steps to identify or mitigate the risks associated with unsecured topical medicines.

Records confirmed temperatures in the area where controlled drugs were stored had exceeded safe operating limits during a recent heatwave. Staff had acted to lower the temperatures; however, records showed these actions had not been effective. There was no information to evidence staff had escalated their findings in line with the provider’s Heat Wave policy to enable additional measures to be put in place.

People told us they received their medicines when they needed them. The provider had recently introduced a management role within the home to strengthen oversight of medicines and support safe practice. Staff had received additional training to administer insulin to people who required it, and this practice was overseen and supported by the district nursing team.

The service used an electronic medicines management system which staff told us supported them to administer medicines safely and as prescribed.