Dove Home Care Agency Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to people’s safe care and treatment.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt or embedded to prevent issues from recurring, as the provider was not consistently proactive in identifying concerns before they arose.

Escalation systems were not always effective, which limited the provider’s ability to identify and respond to risks in a timely way. For example, changes in people’s needs recorded in daily notes were not consistently identified or escalated to management. In another example, a choking incident had not been escalated in line with reporting procedures, reducing opportunities for learning and prevention. Although incidents were responded to when directly raised with the provider, there was limited evidence of systems being used to identify patterns, trends or risks in advance, which may limit opportunities to improve safety and practice.

However, when concerns were raised directly, people and relatives said they were taken seriously and addressed quickly. Staff shared that learning and improving practice was supported by team meetings, training and communication from management. In response to our feedback the provider shared they would start auditing daily logs weekly in order to be more proactive rather than reactive.

The provider did not always work well with people and partners to maintain safe systems of care, and did not consistently monitor safety or ensure continuity.

We reviewed the provider’s Electronic Call Monitoring (ECM) systems and identified concerns such as late visits, unlogged calls, short visits, inconsistent travel time allowance, and instances where staff were recorded as being in two places at once. This reduced confidence in the accuracy of records and increased the risk of missed or rushed care. It was also noted that some staff were working long hours without regular time off, raising concerns about whether they were able to take appropriate breaks. Staff feedback reflected issues with rota planning, with one stating there should be “more consistent rotas, with enough time between visits,” while others reported they were “unable to take a break” or “don’t always have a break” due to time pressures and a lack of cover. People’s experiences were mixed; one person said, “They are occasionally late and I have to phone the office,” and another reported this caused them distress when care was delayed.

However, some people gave positive feedback, describing carers as “very reliable” and “more or less on time,” and valuing the consistency of seeing regular staff.

The provider acknowledged the concerns we found and had begun taking action. This included, reviewing schedules to ensure sufficient travel time was in place for staff, and making efforts to ensure staff have the opportunity to take breaks and regular time off, particularly when working longer hours.

The provider did not always work well with people and healthcare partners to ensure people were protected from harm and able to live safely.

Safeguarding systems were not consistently effective, policies did not provide clear or relevant guidance for staff. Although the service operated nationally, the safeguarding policy only referenced one local authority and did not include wider contact details, increasing the risk of delays or inconsistent responses when concerns arose. Processes were not effective on what staff should do if the safeguarding lead was not available to raise a safeguarding. While they understood what safeguarding was, this indicated a reliance on others to report concerns, which could lead to delays in protecting people. Although staff described a good understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), this was not always reflected in practice. For example, one person was wearing clothing that restricted their ability to remove it; although this was intended to be in their best interests, it had not been recognised or assessed as a potential restriction.

However, people generally reported they felt safe, with comments such as, “I’m very safe and know the carers very well,” and a relative stating, “[The person] feels secure and safe.” Relatives described staff as “polite and patient” and said they helped keep people “calm and safe.” Staff providing care had completed safeguarding training and demonstrated a good understanding of abuse and how to protect people.

The provider was responsive to our feedback and updated their safeguarding policy to include an appendix containing contact details for safeguarding authorities across England.

The provider did not work well with people to understand and manage risks. Staff were not always supported with the information they needed to provide care that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were not always in place, complete, or reflective of people’s needs. Key risks, including skin integrity, choking, diabetes, epilepsy, and moving and handling, were missing or lacked clear guidance, often containing vague instructions such as “carer to monitor” with no detail on actions or escalation. Risk information was not always updated following incidents; for example, one person’s assessment was not reviewed for 17 days after a head injury requiring hospital treatment, with no evidence of monitoring during this time. Some people had no condition-specific plans, including for diabetes and Parkinson’s, and there were no medicines risk assessments in place. Equipment records were not consistently updated, increasing the risk of unsafe use. These issues meant staff may not have had the information needed to manage risks safely.

However, people told us they felt safe when receiving support from staff. One person said, “I’m not put at any risk from the carers.” The provider was responsive to our feedback and took immediate action to begin introducing missing risk assessments and developing risk assessments where further information was required.

The provider did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Environmental risk assessments were in place for people’s homes, however these did not always include clear guidance for staff on how to respond in emergencies, such as a fire, which could result in delays or inappropriate action and increase the risk of harm. Equipment was recorded in risk assessments; however, servicing information was not always complete or kept up to date. For example, one record showed a hoist had been serviced in February 2025 and was now overdue being serviced. The same document listed a hospital bed as “N/A” with no servicing history available, even though a hospital bed was in place. This lack of accurate information means there is no assurance that equipment used by staff is safe and fit for use. The provider was responsive to our feedback and added fire evacuation considerations to risk assessments, however this needed to be rolled out to all people using the service and required time to be embedded in day-to-day practice.

Recruitment processes were not always robust, as safe recruitment practices were not consistently followed and the provider did not always ensure staff received effective training, and competency assessment to carry out their roles safely.

Only one professional and one character reference had typically been obtained, with improved processes only introduced recently in 2026. There was no evidence of full employment histories being obtained, including explanations for any gaps, and no clear attempts to obtain references from previous roles involving vulnerable people. Risk assessments with mitigations were not in place where closer staff monitoring was required. Records for one staff member showed inconsistent reference dates and missing interview documentation.

Not all staff had received appropriate training, and there were no competency assessments for staff delivering specialist care, such as catheter support, increasing the risk of unsafe care. One person told us, “I wish as a whole the agency had more training in mental health,” and staff shared “it would be helpful if refresher training was done face to face.”

However, all staff had completed induction training and said they had shadowing opportunities, which they described as “most helpful” as it showed how the role worked in real homes. There was also evidence of training in key areas such as autism and supporting people with a learning disability. One person said, “There have been no training issues,” and staff felt they had received a good level of relevant training to support them in their role.

The provider responded to feedback raised during the inspection and took immediate action to address these concerns.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People receiving care spoke positively about hygiene standards, with one person detailing that “High standards of cleaning and hygiene” were in place, and that they “consistently observed use of personal protective equipment (PPE)”. Another person using the service shared that staff arrived in uniform and maintained a clean and professional appearance. Systems and policies were in place to support safe practice, including structured shadowing checklists for new staff to ensure they understood when and how to use PPE correctly. Spot checks confirmed that staff had a good understanding of hand hygiene and its importance. Training compliance in infection prevention and control was high, and staff confirmed that this was covered as part of their induction programme, helping them to understand their responsibilities from the beginning.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff were not always supported with clear and consistent guidance, and people were not always fully involved in planning their care.

Care plans contained conflicting or unclear information about medication support, for example one person’s records included differing instructions such as “support,” “prompt,” and “support if needed,” while also stating they did not take medication. Other records were unclear about who was responsible for administering medicines, and some lacked detail on dosages, timings, and monitoring requirements. There was no guidance in place for PRN medicines, or how staff should respond to refusals, side effects, or errors, increasing the risk of inconsistent or unsafe practice.

However, staff had completed medication training and had competency assessments for administering medication in place. Staff also demonstrated a good understanding of safe practice, including gaining consent and escalating concerns. One relative told us they were “impressed with the way they handle my relative’s medication”.