Archived: Dovehaven Nursing Home

Updated 15 May 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. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

As part of this inspection we also 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 completed by two inspectors and a specialist advisor in medicines management.

Service and service type

Dovehaven Nursing Home is a 'care service'. People in care services receive accommodation and nursing or personal care as single package under one contractual agreement. Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the CQC although an application had been made. This means that the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before inspection

Before the inspection we checked the information that we held about the service. This included statutory notifications sent to us by the provider about incidents and events that had occurred at the service. A notification is information about important events which the service is required to send us by law.

We did not ask the provider to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We also obtained feedback from the local authority and healthcare professionals.

During the inspection

We looked around the premises, observed the interactions between people living at the service, care delivery and activities provided at the service. Due to the increased risk of cross-infection we were unable to complete more extensive observations.

We spoke with five people living at the service, one relative and seven staff, including the manager, nursing staff, care staff, domestic staff and a senior manager for the provider. We spoke with three visiting health and social care professionals.

We looked at a range of documentation including two people's care records, medication records, staff files, accident and incident records, safeguarding records, health and safety records, audits and records relating to the quality checks undertaken by staff and other management records.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 15 May 2021

About the service

Dovehaven Nursing Home is a Care Home with nursing and provides accommodation for up to forty elderly people. At the time of the inspection there were 22 people in residence.

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

The management systems needed further embedding to ensure all aspects of care and safety were consistently monitored and improved. Some areas still needed for improvement had not been effectively monitored or actioned in good time. These included updating of the fire risk assessment, medication administration records, care planning for one person and areas signposted around IPC practice.

A routine notification to The Commission regarding a safeguarding incident had not been made at the time.

At our last inspection we found breaches of regulation because sufficient staff were not always deployed to meet people's needs. Enough improvement had been made at this inspection regarding staffing and the provider was no longer in breach of this regulation.

There were concerns with the administration records for medicines. Records did not support safe practice. This meant there was a potential risk some medicines for people might not be monitored effectively and there was a risk some people might not receive their medicines.

The service was not always following best practice guidance regarding the management of COVID-19 and maintaining standards of hygiene and infection control. We signposted the manager to best practice guidance.

People's experience of using the service was positive. People told us they received the care and support they needed when required. Most of the feedback we received showed staff were helpful and kind and treated people with dignity and respect. Positive relationships had been developed between staff and people they supported.

One person commented. “I’ve had a shower this morning and I can get one when I want. Staff are there and I’ve got by call bell if I need them.” Another person said, “The staff can’t be faulted.”

Standard risks assessments associated with people’s care were carried out and managed to minimise harm. Supporting care records mostly identified risks clearly and there were plans in place to help keep people safe.

The current manager was supported by a senior management team. The provider’s governance systems and organisational structure helped provide monitoring and support for the service.

Rating at last inspection and update

The last rating for this service was requires improvement (published 30 December 2020. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

The inspection was partly prompted by concerns raised through safeguarding relating to medication documentation and management of pain relief. We also had other information raising concerns around fire safety, personal care for people and training for staff. A decision was made for us to inspect and examine those risks.

We had previously carried out an unannounced focussed inspection of this service on 16 November 2020. A breach of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment. As part of this focused inspection we checked they had followed their action plan and confirmed they now met the legal requirement for staffing. A further breach has, however, been identified.

This report only covers our findings in relation to the Key Questions Safe and Well led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained Requires improvement. This is based on the findings at this inspection.

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 coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dovehaven Nursing Home on our website at www.cqc.org.uk.

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 a breach in relation to good governance at this inspection.

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.