Drovers House

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 inspection we rated this key question good. At this inspection the rating has changed to requires improvement. This meant the management and leadership was inconsistent. However, leaders and the culture they created supported the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 62 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff demonstrated a shared understanding of the provider’s values and a commitment to delivering care that reflected them. However, leaders had not ensured that systems and processes were effective, which limited their ability to ensure personalised care.

Staff spoke with pride about the home. One staff member told us, “We are different because of the feel of the home. It’s about making the residents smile, going the extra mile.” This reflected a culture where people’s wellbeing and enjoyment were central to the service.

The provider’s values were clearly embedded within the home. When asked to describe them, a staff member said, “Play. Be there. Choose your attitude. Make someone’s day.” These values were reinforced through pictorial prompts displayed around the home, helping staff keep them in mind during their daily work.

The registered manager was focused on ensuring these values were upheld. They had recently introduced a 'jar of joy'containing conversation starters, activity ideas and suggestions for creating meaningful engagement with people. Staff were encouraged to pick a slip from the jar and carry out that activity during the day. This supported a culture of positive interaction and connection, helping to make people’s experiences more enjoyable and personalised.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. They did so with integrity, openness and honesty.

Leaders at all levels created an inclusive and supportive culture where staff felt valued and worked together as a team. Staff told us they felt well supported by the leadership team and described a strong sense of teamwork and pride in the care they delivered. Many leaders within the organisation had progressed internally and continued to work alongside staff.

The registered manager was visible and actively involved. They knew people and their relatives well and were available around the home to offer support, guidance and reassurance. Relatives told us the registered manager delivered care when needed, and people living in the home said they knew the registered manager well and felt comfortable approaching them.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

People felt able to share concerns with staff or the registered manager who they described as ‘visible’, ‘active within the home’ and ‘readily available’. Comments included, “The manager will speak to me. We can have a laugh and a joke with the manager. [Manager] does ask me for feedback,” and “I speak to the manager if I have any concerns. They are very nice to chat to.”

Staff felt confident talking to managers in the home and described the registered manager as supportive and approachable. Staff were also aware of other staff within the provider organisation they could speak to if needed, demonstrating a clear understanding of escalation methods available to them. This helped promote a culture where people and staff felt listened to and empowered to speak up.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Staff described an inclusive environment where equality and diversity were celebrated and promoted. Staff were recognised for longevity awards, and when staff achieved qualifications, this was celebrated across the provider group.

The registered manager recognised night staff may not have the same level of opportunities to meet with the management team and share their thoughts and ideas. To address this the registered manager often started work early so they could meet with staff before the end of the night shift. They also scheduled night staff meetings in the evening so all night staff could attend and had responsibility for 1 to 1 meetings with the night staff team.

The provider did not have clear responsibilities, roles, systems of accountability and good governance

The provider did not have effective governance arrangements in place to ensure the quality and safety of the service. Systems to monitor compliance, were not operating as intended, and this meant issues we identified during the inspection had not been recognised or addressed. Known risks had not been mitigated, and the provider had not ensured that processes designed to keep people safe were consistently followed.

Care records were not reliably maintained, and the provider had not ensured that care plans contained accurate, up to date information to guide staff. This exposed people to the risk of avoidable harm because staff were not supported by clear, person‑centred documentation. Despite having systems in place, these were not used effectively to identify gaps in risk management or to ensure staff had the information they needed to deliver safe care. As a result, people were placed at risk of harm, and incidents that may have been avoided, for example people falling, choking or losing weight, were not mitigated against.

The provider’s audits and checks had failed to identify that were evident during our inspection. For example, hot water was running cool in some communal toilets, and staff were observed working while wearing jewellery, contrary to infection prevention expectations. These issues should have been identified through routine monitoring but were not, demonstrating a lack of robust oversight.

Standards and areas of regulatory compliance had not been maintained. Failures in risk management and record keeping had gone unnoticed, indicating that leaders did not have effective systems to assure themselves of the quality and safety of the service.

Policies and procedures did not consistently reflect best practice guidance, including those relating to medicines management and infection prevention and control. They did not clearly set out the provider’s expectations for staff, which contributed to inconsistent practice and a lack of accountability.

These shortfalls in governance processes meant the provider did not have effective arrangements to assess, monitor or improve the quality and safety of the service. This placed people at risk of avoidable harm and demonstrated a significant failure of governance systems.

Throughout our inspection the registered manager and provider’s service managers were open and honest. They welcomed our inspection and acknowledged our inspection findings. The registered manager shared there had been instability in the home’s management team and they recognised this had impacted on addressing required improvements. Following our inspection visit the provider assured us they were committed to strengthening their assurance and sustainability process and had prioritised updating care plans for those at highest risk.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The service worked positively with families, healthcare partners and the wider community. Staff maintained strong partnerships with relatives and kept them updated when any changes occurred in people’s care. One relative told us, “I visit every day, but they always phone us if they need to, they make sure we are kept up to date about everything.”

Relationships with healthcare services were positive. Staff worked closely with visiting professionals to ensure people received timely and coordinated support.

The home was well connected to the local community. There were links with churches, faith groups, schools and nurseriesand a range of community organisations, helping people maintain social connections and participate in meaningful activities. These partnerships supported a sense of belonging within the wider community.

The provider focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff told us that learning from incidents was shared across the provider group,enabling teams to reflect together and strengthen practice. This supported a culture where improvement was seen as a shared responsibility.

Innovative approaches were being used to enhance people’s wellbeing and safety. The provider had introduced circadian lighting in some areas of the home. Circadian lighting is designed to mimic natural daylight and support healthier sleep–wake cycles, particularly benefiting people living with dementia. Staff also used acoustic monitoring at night time, overseen by duty staff at a central hub. This reduced the need to disturb people overnight while still ensuring their safety and meant night staff could provide support promptly when concerns arose.

The provider had also taken meaningful steps to reduce its environmental impact. A sustainability strategy focused on waste reduction, recyclingand energy efficiency.Most recently, solar panels had been installed at the home to reduce energy waste and support long‑term environmental goals.

These initiatives showed the provider’s commitment to innovation and improvement, with positive effects on people’s experiences, staff practice and the wider environment.