Archived: Dovehaven House

Updated 30 July 2021

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 Care Act 2014.

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 undertaken by two inspectors and one medicines specialist.

Service and service type

Dovehaven House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

Both days of the inspection were unannounced.

What we did before the inspection

We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with four people who used the service and four relatives about their experience of the care provided. We spoke with eleven members of staff including the provider, registered manager, members of the senior management team, deputy manager, senior care workers, care workers and a domestic worker. We 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.

We reviewed a range of records. This included seven people’s care records and multiple medication records. We looked at two staff files in relation to recruitment. A variety of records relating to the management of the service and quality assurance.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at the providers action plan from our initial inspection findings.

Updated 30 July 2021

About the service

Dovehaven House is a residential care home providing personal care to 38 people at the time of the inspection. The service can support up to 40 people and specialises in providing care to people living with dementia.

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

People were not consistently supported in a safe way. We found people had not always been effectively risk assessed for use of moving and handling equipment or bedrails. The provider responded quickly to our inspection findings and made immediate improvements to ensure people’s care plans reflected the safety equipment needed.

People’s medicines were not always managed in a safe way. We found medicine record keeping was not always accurate and this meant people were at risk of not receiving their medicines as prescribed.

On the first day of the inspection we found areas of the environment unclean and furniture was worn making it difficult for domestic staff to efficiently clean. The provider had commenced a full environment refurbishment plan and on day two of the inspection we saw cleanliness standards had improved.

On the first day of the inspection staff did not consistently follow safe Infection Prevention and Control (IPC) standards, on the second day of the inspection standards had improved. The provider had up to date procedures in place for IPC and COVID-19 guidance for staff to follow. Staff received training in best practice standards for the prevention of infectious disease and also had access to a COVID-19 hotline which the provider had set up to allow staff to raise concerns or ask questions.

On the first day of the inspection we found some people’s emotional and personal hygiene needs had not been met. We discussed this with the registered manager who took immediate action to improve standards. On the second day of the inspection we found staff were responsive and acknowledged people’s needs in a timely and effective way. Relatives consistently told us they felt service users were safe, well cared for and respected.

Quality monitoring systems were not always effective to monitor people's safety. Failures highlighted at this inspection in relation to environment hygiene, medicines, bedrail safety and moving and handling assessments had not been identified by the registered manager. We were assured by the providers response to our findings and their actions taken to ensure immediate improvement.

The provider had introduced Person Centred Software, an electronic system to support effective record keeping. However, staff did not always maintain accurate and contemporaneous record keeping.

Staffing levels were planned in line with dependency needs of people who lived at the service. Staff were recruited in a safe way. Staff told us they enjoyed their induction training and felt supported to understand the needs of people who lived at the service

Staff followed safeguarding processes, we found alerts had been made to the Local Safeguarding Authority following allegations of abuse. Staff demonstrated good knowledge of safeguarding processes and told us they felt confident to raise any concerns internally and externally.

Accidents and incidents were recorded, preventative action was taken and lessons learnt at service and provider wide level.

Staff told us they were able to seek support from the manager and deputy manager. Relatives told us they felt involved and communication was good when people’s needs changed.

The registered manager submitted statutory notifications and was aware of their regulatory responsibilities.

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 good (published 06 November 2017).

Why we inspected

The inspection was prompted in part due to concerns received about the care and treatment people received. A decision was made for us to inspect and examine those risks.

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.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, medicines management and governance. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.