Dovehaven House

Updated 2 June 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

This inspection was carried out by 1 inspector 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

Dovehaven House 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.

Dovehaven House is a care home without 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 not a registered manager in post. A new manager had been in post for 4 months and had submitted an application to register. We are currently assessing this application.

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 carried out a tour of the home to ensure it was safe and suitable to meet people's needs. We also observed the delivery of care and support at various times throughout the day. We spoke with 10 people who lived at the home, 7 relatives, the manager, the head of compliance, the regional manager, the cook and 4 members of care staff.

We looked at records in relation to people who used the service including 5 care plans, medication records and systems for monitoring the safety and quality of the service provided. We also looked at 3 staff recruitment files.

After the inspection

We continued to seek clarification from the provider to validate evidence found. We looked at staff training and quality assurance records.

Updated 2 June 2023

About the service

Dovehaven House is a residential care home providing personal care to up to 40 people. The service provides support to older people, including those living with dementia. At the time of our inspection there were 38 people using the service.

Accommodation is over 2 floors with a lift providing access to the first floor. There was a communal dining room and lounge across both floors. People had access to an outdoor courtyard and a rear enclosed garden.

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

Although we were assured people received their medicines as prescribed, records were not always accurate, such as stock balances of medicines.

Although we were assured people were receiving the care and support they required, records were not always maintained in a way which best evidenced this.

Some audits carried out by the manager did not always contain well defined action plans to help address shortfalls.

We have made a recommendation about the management of medicines and a recommendation that the provider reviews governance systems to ensure record keeping and audit processes are operated effectively.

Staff were recruited safely and there were enough staff to meet people’s needs. Health and safety checks were carried out to ensure the home was a safe environment for people to live in. Risks to people were managed and mitigated by staff to lessen the risk of harm to people.

People and their relatives told us they felt safe living at Dovehaven House. Accidents and incidents were used as learning opportunities to help improve standards. The home appeared clean and well maintained. The home was in the process of undergoing refurbishment to help further improve the quality of peoples’ environment.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and their relatives were keen to tell us staff were kind and caring and treated them in a way which respected their dignity and independence. The home facilitated activities and experiences which were meaningful and unique to people.

There was a manager at the service who was in the process of applying to become registered with CQC. We received positive feedback about the impact the manager was having on the home and staff morale. The manager was well supported by the provider and had already identified and was addressing our findings at this inspection.

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

Rating at last inspection

Although the home is owned by the same provider as at our last inspection, there has been a change in legal entity (how the provider is registered). The last rating for the service under the previous legal entity was requires improvement, published on 30 July 2021. At that inspection we found breaches of Regulation 12 and 17.

This is the first inspection of this service under the new legal entity.

Why we inspected

We carried out this inspection to award the service a rating under its new legal entity.

We have found evidence that the provider needs to make improvements. Please see the well-led section of this full report.

We also 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.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.