Archived: Sovereign House

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

Responsive – this means we looked for evidence that the provider met people’s needs.

At our last assessment we rated this key question Good. At this assessment the rating has changed to Inadequate. This meant services were not planned or delivered in ways that met people’s needs.

The service was in breach of legal regulation in relation to person centred care and gathering and acting on feedback about people’s experience of care.

This service scored 29 (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 make sure people were at the centre of their care and treatment choices and they did not work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

People’s care plans were not detailed and did not reflect their mental, emotional and social needs, including those related to protected characteristics under the Equality Act.

People were not supported to take part in a range of activities and pastimes they enjoyed. Professionals visited twice monthly to support people to take part in exercise or hand massage but no other activities took place at the service. We observed most people spent the day in the lounge with the television on, some people dozed in their chair. Staff did not engage with people except when supporting them with their care needs. A staff member told us, “We don’t have much time to support activities but try to spend time with people.” There was a risk people would become isolated and withdrawn.

People and their representatives had not been fully involved in planning and making decisions about people’s care, so it was centred around them and their needs. Care was based around a routine established by the registered manager. For example, staff meeting minutes showed 3 people were to be supported to the toilet at 4pm, 2 people went to bed at 5pm and another at 6.20pm. We would expect people to be able to make a decision each day about when they wished to go to bed unless they had made a decision to go to bed at a specific time each day. There was a risk people’s choices and wishes would be discounted and they would not be involved in planning their care and support.

There were some shortfalls in how the provider understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

People had not been supported to be part of their local community. People were not enabled to take part in community events or to use local services such as cafes and the library. There was a risk people would be isolated from their community.

As care plans and risk assessments did not reflected people’s current needs, we could not be assured people received consistent care. Care plans did not contain information for staff about how to provide people’s care, such as oral care or moving and handling. There was a risk people would not receive safe and consistent care in the way they preferred.
 

The provider and registered manager did not supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs. Information had not been made available to people in ways they could understand, such as large print or easy read.

An easy read version of the complaints process had been created and pinned to a notice board. However, the notice board was behind a locked door in the entrance hall and was not accessible to people in the service. When the front door was opened the door covered the notice board, so the policy was not visible to people coming into or leaving the home. We asked the registered manager about other accessible information and they told us they had not considered it was necessary and people could ask if they needed anything. This relied on people having the confidence to request information, rather than it being available to them whenever they wanted it. There was a risk people would not have access to important information when they needed it.

The provider did not make it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff did not involve people in decisions about their care or tell them what had changed as a result.

The provider’s statement of purpose informed people that they had processes in place to ask them about their experiences of the service and make suggestions for improvements, thorough ‘Residents’ consultation and satisfaction surveys’ and ‘Residents’ meetings’. The satisfaction survey had not been completed since February 2023 and the registered manager was unable to tell us why surveys had not been completed since then. Residents meetings were not held regularly and 2 had taken place in 2025. We reviewed the minutes of these meetings which showed people had not been asked for, or supported to share feedback about the service they received, or make any suggestions for improvements. There was a risk people would not receive care which met all of their needs.

The provider had not followed their complaints procedure when complaints had been received. A complaint had been received from the local authority about the care a person had received. This had been reviewed by the registered manager who concluded the person had made a complaint to Kent Fire Rescue Service about the service. They had not considered the feedback they had received about the service, including out of date information about the person and a lack of regular reviews of their care, and minimal action had been taken to address the concerns. For example, some people’s care plans and risk assessments had been reviewed but others had not. There was a risk complaints received would not drive improvements at the service.

The provider and registered manager did not make sure that people could access the care and support they needed when they needed it.

The provider had not considered any barriers to people accessing care when they need it and in a way that worked for them. They had not taken action to promote equality for all. People’s care was not planned and delivered in line with best practice, quality standards and legal requirements, such as making reasonable adjustments for disabled people, addressing communication barriers and having accessible premises. For example, we observed when a person had gone into the rear garden no arrangements were in place for them to inform staff they wanted to come back in. We observed the person walking around in the garden and the provider told us, ‘They probably want to come in’. They provider let them in but the person had to wait until someone noticed they wanted to return rather than there being a bell or other way of them informing staff. People were not able to come and go from the garden when they wished.

The provider had not considered how they would obtain and use people’s feedback to improve access for people more likely to experience barriers such as people living with dementia or a physical disability and there was a risk their needs would not been considered when planning changes to their care or the service.

The provider and registered manager did not listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not tailored in response to this.

The provider and registered manager had not considered that people using the service could be victims of discrimination and inequality, and had not looked at ways to address any barriers and improve people’s experience. For example, the needs of people living with dementia had not been considered when planning the care environment. Signs and pictures had not been used to support people to understand the different areas of the building, what was happening each day or choices they had. There was a risk people would not be supported to have access to all the information and support they needed to remain as independent as possible.

People were not supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

People had not been given the opportunity to share their views about care at the end of their life, including where they would like to be, who they would like to be with them and any cultural and spiritual needs. There was a risk people would not receive the care and support they wanted, in the way they preferred, at the end of their life.

People had made advance decisions with their families and health care professionals, including ‘Do not attempt cardiopulmonary resuscitation’ directives (DNAR) and advanced care plans. However, the most up to date versions of these documents were not always available to staff. For example, before our assessment a social worker told us when they had reviewed a person’s records they found the most up to date DNAR and advanced care plan were not in place. The DNAR on record was dated 2017, and had not been replaced with the updated DNAR completed in 2022. This increased the risk people would not receive treatment in the way they had agreed with their health care professionals.