The Care Quality Commission (CQC) has rated Drovers Call in Lincolnshire, inadequate and placed it in special measures to protect people, following an inspection in September.
Drovers Call is a care home which provides accommodation for older people, some who are living with dementia. The home can accommodate up to 60 people. At the time of this inspection there were 56 people living at the home.
The inspection was prompted in part due to concerns received about the use of restrictive practices, mental capacity assessments, information systems and leadership.
Following the inspection, as well as the overall rating for the service dropping from requires improvement to inadequate, the ratings for safe and well-led have also declined from requires improvement to inadequate. Caring and responsive have fallen from good to requires improvement and effective has declined from good to inadequate.
Due to breaches being identified in relation to risk management, restrictive practices, safeguarding, leadership and information systems, CQC has placed urgent conditions on the provider’s registration.
The service is now in special measures, which means it will be kept under close review by CQC to keep people safe and re-inspected to check sufficient improvements have been made.
Amanda Lyndon, CQC deputy director of operations in the midlands, said:
“When we inspected Drovers Call, we were disappointed to find a deterioration in the standard of care people were receiving. The lack of oversight from the provider and registered manager had led to a decline in the safety and quality of care people were receiving.
“There were signs of a closed culture where restraint was overly used. For example, a person was regularly restrained by two staff, while a third provided personal care. This restraint wasn’t included in their care plan to show this was necessary. Another record showed a person was let free because they promised to calm down. Treating people this way is totally unacceptable and people living at Drovers Call should be treated with more dignity and respect.
“Additionally, medication was being used more than it should have been to manage people’s distressed behaviours, this also wasn’t included in care plans. For example, a person was restrained a total of 11 times in one month, and there was no record of why this medication was given to deal with this situation.
“We also found the home environment wasn’t always clean or well-maintained which put people at risk of infection. There were bodily fluids in lounges and corridors. These communal areas were frequently used by most people living in the home, which could put them at risk.
“The standard of care people were receiving at Drovers Call was unsafe, undignified, and totally unacceptable. People living at this home deserve better care and treatment.
“Following our inspection, we reported our findings to the provider so they know where we expect to see rapid improvement. If sufficient progress is not made, we will not hesitate to take further action to ensure people’s safety and well-being.”
Inspectors found:
- 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. There was a lack of support plans and assessments in place which 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
- The service did not have enough staff, a high number of agency staff were used, significantly increasing the risk of inconsistent care
- The service did not always follow or act in accordance with the Mental Capacity Act (MCA)
- 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.
The report will be published on CQC’s website in the next few days.