Archived: Dovehaven

Updated 30 October 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This was an unannounced inspection which took place on 3 and 4 October 2018. The inspection team consisted of an 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. The Expert by Experience had experience with the care of older people.

Before the inspection we reviewed records held by CQC which included notifications and any safeguarding concerns. A notification is information about important events which the registered person is required to send us by law.

Before the inspection we received a completed Provider Information Return (PIR). This document gave the registered provider the opportunity to tell us about how the service delivers safe, effective, compassionate and high-quality care to people and what plans they have in place to continue to make improvements to the service. We also contacted the local authority commissioning team to ask for their views. We used all this information to plan how the inspection was conducted.

During the inspection we met and spoke with the registered manager, deputy manager, registered provider, the registered provider’s compliance manager and a regional manager for the Dovehaven group. We also met and spoke with five staff (carers), the chef, 10 people living in the home and six relatives. We received positive feedback from community-based health professional who was supporting people in the home.

We looked at the care records for four of the people living at the home. We also looked at 10 medication records, three staff recruitment files and other records relevant to the quality monitoring of the service. These included safety audits and quality audits including feedback from people living at the home and relatives. We undertook general observations and looked round the home, including people’s bedrooms, bathrooms and the dining/lounge areas.

Updated 30 October 2018

The inspection took place on 3 and 4 October 2018 and was unannounced.

Dovehaven is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Dovehaven is a care home providing accommodation and personal care for up to 40 older people. There were 37 people accommodated at the time.

The service had a registered manager in place at the time of the inspection.

A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008.

The last inspection of Dovehaven took place in December 2017 and was a focused inspection to follow up on two breaches of regulation in relation to fire safety, staffing, and governance. These breaches had been identified at the comprehensive inspection in July 2017. At the focused inspection we found the provider had acted to meet the breaches and the requirements were met. The service was rated good at the inspection in December 2017; the rating remained good at this inspection.

People and their relatives said they received safe care and attention in accordance with their individual needs. They also said the staff were polite and caring and this we observed during the inspection.

People's plan of care considered risks to people’s safety and wellbeing. Plans were in place to minimise these risks. Systems were in place for the recording and monitoring of accidents and incidents to identify any trends or patterns that may occur.

People had a plan of care which was centred around their individual support needs. This included plenty of information about their routines, likes, dislikes, preference and choices to enable staff to deliver this how they wished.

People were supported with their eating and drinking needs and staff were aware of people’s personal likes and dislikes in relation to what they ate.

People were fully involved with decisions about their support. Their consent was sought around day-to-day decisions and they were fully involved in any changes made.

The registered provider worked in accordance with the Mental Capacity Act (MCA) 2005 and staff demonstrated a good knowledge around how this was applied in a care setting.

There was an open culture which people and staff were encouraged to speak up if they had concerns. Staff had received training in the protection of adults and knew what action they should take if they suspected or witnessed abuse.

Staff were knowledgeable regarding people’s care and support. Staff had a good understanding of how people liked to communicate and wished to be treated.

We saw liaison with external professionals to support people with their care needs. Referrals to them were made appropriately. For example, doctors and district nurse teams.

People were supported to follow their chosen interests and maintain relationships with relatives and friends that mattered to them. The registered manager was looking at providing a more varied activities programme as they appreciated more events needed to be organised.

Recruitment practices were robust and this helped ensure that only people suitable to work with vulnerable people were employed by Dovehaven.

The management of medicines was safe and medicines were administered by staff who were trained and deemed competent.

Staff supported people with end of life care. Advice and support was available from the district nurse team and other relevant health professionals when needed.

Policies and procedures provided guidance to staff regarding expectations and performance in accordance with current legislation and best practice.

Staff received training which provided them with the skills and expertise to undertake their work safely. This included more specific training to meet more complex conditions and opportunities for staff development. New staff received a comprehensive induction training programme to support them.

Staff members we spoke with fully understood the importance of acknowledging people’s diversity, treating people equally and ensure that they promoted people’s rights.

The registered provider had a complaints’ policy and procedure. Complaints received were logged and investigation in accordance with home the complaints’ procedure.

Confidential information was stored appropriately to maintain people's privacy.

Systems and audits were in place to regularly check standards and to support the continual development of the home.

Further information is in the detailed findings below.