Dove Home Care Agency Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulation in relation to governance at the service.

This service scored 57 (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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager described a clear ethos focused on maintaining a strong, caring reputation, promoting a “family” feel, and continually improving the service, including embracing new approaches and technology. People consistently spoke positively about their experiences, with one person explaining how staff had supported them to live independently in the community after a long hospital stay, and another describing the service as “professional and caring” and not like a large corporate organisation. People also highlighted the accessibility of the office, with one stating they received responses within a few hours, and others said they would recommend the service and felt it was “well run and under control.” Relationships with management were described as positive, with comments such as “The manager is very understanding.” Staff feedback also reflected a supportive and inclusive culture, describing their experience working for the service as “pleasant and amazing.”

Not all leaders understood the context in which the provider delivered care, treatment and support, and did not consistently demonstrate the skills, knowledge, experience or credibility required to lead effectively. As a result, the provider did not always demonstrate strong, consistent leadership to ensure effective oversight of the service.

While most staff described management as approachable and felt able to communicate openly, the registered manager did not consistently maintain oversight of the service and relied on another member of the management team to do so. The manager described seeking guidance from external networks and relying on peer support, which showed a willingness to develop, but this did not fully translate into robust, day-to-day leadership and accountability within the service. Although the manager demonstrated an understanding of their regulatory responsibilities, including when to submit notifications, their oversight was not consistently effective in practice.

People did not always feel they could speak up and that their voice would be heard.

While some staff described management as “supportive and approachable” and said they felt listened to during regular check-ins, this was not consistent across the service. One staff member reported that concerns about colleagues were not listened to. There were also examples where staff did not feel supported following incidents. For example, one staff member described an incident happening with a person they were supporting and felt the response from management did not take the matter seriously, as they were quickly assigned another visit without appropriate follow-up. Another recalled concerns they had shared with management, where the response focused on changing staff rather than addressing the issue. These experiences meant some staff did not feel fully supported or confident that concerns would lead to meaningful action.

However, systems such as a whistleblowing policy and opportunities to raise concerns during supervision were in place.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Most staff had completed equality and diversity training and demonstrated a good understanding of these principles, including recognising and responding to discrimination. Staff told us they felt confident to raise any concerns with the manager and described the workplace as inclusive and respectful, with one member of staff explaining they had not witnessed or experienced any discrimination. The provider also supported staff well by making reasonable adjustments where needed. For example, one staff member described how they were supported during a period of ill health, including being able to work from home, receiving suitable equipment to improve their comfort, and having flexible working hours agreed. They also shared that the manager kept in regular contact to check on their wellbeing, which they found reassuring.

The provider did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance processes were not effective in identifying and addressing concerns, as several issues found during the inspection had not been recognised through existing systems. These included gaps in care records, concerns within call monitoring data, delays in medicines oversight, and missed opportunities to respond to changes in people’s needs. Policies did not reflect the full scope of the service; for example, guidance for lone working and safeguarding did not adequately support staff delivering live-in care across different locations, increasing the risk of inconsistent or delayed responses to concerns. Auditing systems were ineffective, with delays in reviewing medicines administration and insufficient oversight of care records. This meant risks, including changes in people’s health such as increased agitation or deterioration, were not identified or acted upon. There was limited evidence of trend analysis or learning from incidents, and key risks relating to health conditions and the use of restrictive practices were not identified. These shortfalls demonstrated a lack of effective oversight and continuous improvement, placing people at risk of unsafe or inappropriate care.

In response to our feedback, the provider introduced a Live-in Lone Worker policy and employed additional Care Quality Monitoring Officers (CQMO) to support oversight of the service. The provider advised that the CQMO role would further strengthen the service through monitoring rotas, reviewing call times, and auditing records to identify and address concerns promptly.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

There were examples of effective collaboration with services such as occupational therapy, speech and language therapy, and dementia teams. This helped ensure people got the relevant support they required. For example, one person was supported to use specialist equipment following an occupational therapy referral, which enabled them to use the toilet independently rather than a commode. Staff and leaders described clear processes for making referrals and adapting care plans where specialist input was required, and they took part in multi-disciplinary meetings to ensure a joined-up approach.

However, these partnerships were not always fully effective, as concerns were not consistently identified in a timely way, meaning opportunities to involve external professionals and improve outcomes could be missed.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

There was limited evidence of structured approaches to learning from feedback, incidents, or best practice, and the service was not engaged with recognised quality improvement initiatives, accreditations, or research.

However, the provider had begun exploring the use of new technology, including an AI system to support assessments and person-centred care planning. Early testing showed this could improve the quality and person-centred nature of care plans by capturing detailed information and reducing the risk of important details being missed. Despite this positive step, the system was not yet fully implemented, and its impact on improving care and outcomes had not been demonstrated. As a result, innovation and continuous improvement were not yet embedded across the service.