Dover House

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 inadequate. This meant people were not safe and were at risk of avoidable harm.

The service was in breach of legal regulations in relation to people’s safe care and treatment, the way people’s medicines were managed safely, safeguarding people, maintenance of the premises and equipment and staffing.
 

This service scored 28 (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 have a proactive and positive culture of safety based on openness and honesty. They did not listen to concerns about safety and did not investigate or report safety events. Lessons were not learnt to continually identify and embed good practice.

Accidents and incidents had not been effectively monitored and analysed to identify themes, mitigate risks and prevent further occurrences. An overall view of accidents and incidents to learn lessons and keep people safe, by ensuring the appropriate mitigation measures were in place, did not capture all incidents and did not produce action to improve outcomes for people.

There were incidents of people displaying anxious, distressed and aggressive behaviours resulting in people being harmed by others living in the service. There were incidents of people with unexplained bruising, and these had not always been recorded. People experienced falls, both witnessed and unwitnessed and these were not always recorded. Staff had not always recorded events as incidents, so were not captured to enable lessons to be learnt to prevent further occurrence. The provider had not identified this.

Analysis was not undertaken to minimise the risk of injury and distress. Although an incident monitoring system was used by the provider to look at the recorded incidents each month this was ineffective, incidents were missing from this and action was not taken as a result of monitoring, so opportunities were missed to improve people’s safety and quality of life.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

People’s safety was not robustly monitored or managed. Risk assessments were not always adequate, and some risks had not been assessed appropriately, reviewed or mitigated. This meant that information passed to other agencies such as hospital staff would not contain accurate information. There was a risk people could come to harm when being supported in hospital by staff who did not know them well because their needs and risks were not adequately recorded.

Staff had not always sought advice, or when they had, followed the advice given by other healthcare professionals, to ensure people’s care was joined up and met their needs. For example, when treating wounds and pressure sores, supporting people’s anxieties to minimise distressed or disorientated behaviour and repeated falls.

The provider did not work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not share concerns quickly and appropriately.

Not all events, such as accidents and incidents that may constitute the abuse of a vulnerable adult were raised with the local authority, in line with local safeguarding vulnerable adults’ protocols. For example, a person had raised a concern around their care and safety with their relatives who then reported this to the management team. The person’s concerns in relation to their safety had not been referred to the local authority safeguarding team, whose responsibility it is to investigate allegations of abuse. The management team investigated the concerns raised internally but had not considered referring the incident externally which placed the person at risk of further abuse.

People were observed to have bruising that was unexplained. Visiting healthcare professionals had also found unexplained bruising on people. Some bruising has been recorded by staff and some had not. Records by staff did not always show a full investigation had been undertaken to try to identify cause and determine if incidents met the threshold to follow local authority safeguarding protocols.
Staff did not always know how to report safeguarding concerns outside of the service. A staff member said, “I would have to google it as it is not posted up in the home.”

Relatives had mixed views about their loved one’s safety including, “No, I don’t think my loved one is safe. The reason is there have been a few incidents”, “Well there has been a number of incidents. I don’t think he is unsafe, but others might be” and “Loved one is safe, they have 1 to1 care so always has someone with them which I think is a blessing.”

Where relevant, a Deprivation of Liberty Safeguards (DoLS) application had been made when people had been assessed as lacking the capacity to consent to their care and treatment at Dover House.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.
The provider failed to do all that was reasonably practicable to keep people safe from avoidable harm. Staff did not have the guidance necessary to provide safe care for people living at the service.
People did not have specific risk assessments to identify individual risks in relation to their particular health conditions and care needs. This meant measures were not in place to minimise risks.
We found many concerns around individual risk management including wound care, catheter care, falls and distressed behaviours. People’s wounds were not dressed in a timely way when needed to enable comfort and prevent wound deterioration. People had unravelling and stained bandages which increased the risk of infection.

We identified a person with a catheter in place had passed limited urine over a 24-hour period and this had not been noticed. The person’s records showed they did not have sufficient fluid intake to keep them healthy. Over the previous 6-day period, their fluid intake had been far less than their recorded recommended intake of 1500 mls over 24 hours. This had not been identified, and action had not been taken to ensure the person received appropriate care and support to prevent deterioration in their health.
Another person was on a restricted fluid regime due to their medical conditions, to prevent further complications to their health. Their fluid intake was in excess of their recommended fluid limit most days. For example, in a 7-day period they had in excess of their recommended daily intake every day except 1. This had not been picked up and action taken to reduce the amounts. This put the person at risk of harm from deterioration of their health.

There were many incidents of people falling over, sometimes witnessed and sometimes unwitnessed. Sufficient guidance to mitigate against the risk of falling was not in place. Although movement sensor mats were in place for some people, these had not always been effective and were not sufficient to detect movement or falls away from a person’s room. There were many incidents of people being distressed and becoming aggressive towards others and people had been assaulted more than once. People had bruises that were unexplained. However, investigation into how the bruising may have happened had not been undertaken, in order to review and update people’s care plans and risk assessments.
People’s care plans were general and not specific to individual needs, which would often vary significantly. The guidance in place for staff and agency staff was inadequate and did not describe the care and support people needed to stay safe on a day-to-day basis.

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

The premises were poorly maintained and people, particularly on floors 1 and 2, were living in an extremely poor environment. The flooring, furniture and equipment were inadequate in providing a clean and safe place for people to sit and walk around.
We found an overpowering smell of urine on floors 1 and 2, creating an extremely unpleasant environment for people to live in. Carpets in the lounge areas were dirty and significantly malodorous. Laminate flooring in corridors and some people’s bedrooms were sticky to walk on.

Many people’s bedrooms were not personal, were bare and without homely touches. A person’s bedroom was in such a condition, their upholstered chair was unclean, and it was missing a seat cushion, their wardrobe had a door missing. The room had a malodour and their clothes hanging in the wardrobe smelled as a result.

There were complaints recorded from relatives where they had raised their concerns back to January 2025 about the poor environment and the smell of urine. However, no effective action had been taken and the issues remained. A relative told us how their clothes smelled after sitting in the lounge area with their loved one. We found the same situation, as our clothes smelled after sitting in the lounge areas.
A relative said, “The home used to be clean but last time I visited it wasn’t clean, and it did smell as well. The lounge was dirty, the floor seemed dirty, and the chair had something on it, not sure what.”

The provider told us during the assessment they would immediately seek quotes to replace furniture and flooring where necessary and would keep us informed of progress. The ground and 3rd floors were better maintained and did not have the same malodours as found on floors 1 and 2.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

There were insufficient staff to meet people’s needs during the night shifts. Although a staffing dependency tool was used by the provider to determine staffing numbers, this did not take into account collective numbers of people who required staff care and support at the same time. For example, people who were mobile, awake and walking around disorientated or distressed and needed staff to try to allay their anxieties by providing significant time and intervention, and people who were not mobile and needed care in their bedroom at the same time. We found 2 care staff on duty on each floor unable to do this. For example, 1 person was walking around disorientated and requiring staff attention as they were unable to articulate their needs. A staff member needed to remain with the person, which meant there was only 1 other carer available for the 27 other people on that floor. Although a nurse was on duty, they spread their time across 2 floors and were required to provide for people’s clinical needs.
The provider agreed to immediately increase the staffing numbers at night when we brought this to their attention. This meant people would receive safer care, however the provider and registered manager had not identified and taken action in relation to staffing levels until we raised our concerns.

Although staffing numbers through the daytime appeared sufficient, staff did not have the training and skills required to ensure people received safe and good quality care and support. There were 8 registered nurses. Some of them were out of date in completing 3 clinical based training courses. All 8 nurses had not completed 1 of these training courses. The provider and registered manager had not identified the poor wound care being administered by nurses, therefore not ensuring people received the appropriate clinical care they required.

Care staff had not completed training for continence, diabetes, nutrition and catheter care, despite providing care and support to people with these significant needs. We identified concerns of poor care in all these areas.
Staff did have regular 1 to 1 supervision with a senior member of staff, however, the areas of concern we found during our assessment had not been identified or action taken to improve staff skill and ability.

We received mixed views from people and relatives about staffing levels and abilities, including, “They seem to have enough”; “No not enough staff”; “A lot of the staff do have the skills, but they use agency so maybe not.”

Staff had been recruited safely; the required checks had been completed to make sure staff were of good character.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The risk of infection was not controlled to prevent spreading. The environment was poorly cleaned and maintained. Although we saw domestic staff cleaning throughout the assessment, the floors and furniture continued to significantly smell. Surfaces such as people’s bedside tables, although wiped, remained smeared and sticky. Floors, although just mopped, remained sticky.
A relative told us, “Several times I have visited and there have been faeces on the floor in (loved one’s) bedroom, on the walls and on the toilet frame and chair where they wash. One time the chair (loved one) was sitting was soaked with faeces and someone came in and just flipped the cushion over leaving the pad on the chair underneath.”

Some people had leg wounds that were visibly leaking. Wounds were not dressed appropriately and as described in their care plan with absorbent dressings until late afternoon/evening which meant there was wound leakage to the floor throughout the day as people were independently mobile and walked around. When we checked a person’s care records, we found dressings were not prioritised until late in the day most days. This meant the person was at increased and ongoing risk of infection, and there was a risk to other people of acquiring infections. A person was found to have a wound-based infection on admission to hospital and another person on admission to another care home. The risk of infection spreading was significantly heightened by the poor cleanliness and poor prioritisation of wound management.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. People were not involved in planning.

People’s medicines were not always managed safely. We checked a selection of people’s prescribed medicines. All but 1 person had medicines in stock that did not tally with the numbers that should have been in stock, based on how many medicines were received into the service, and how many had been signed as being given. People were at risk of not receiving the amounts of medicines they needed to stay well, placing their health at risk.

Some people had their medicines given covertly. This meant they had their medicines disguised to ensure they took the medicines they required to keep them well, such as in yoghurt or a drink. Covert medicines were not always managed safely to ensure the way people were given their medicines was safe. A person had their medicines disguised in their meal. However, we found the person often did not eat their whole meal or declined their meal. There was no record of what action, if any, had been taken to mitigate the risk of not receiving their medicines, or liaison with the GP to review the way in which they took their medicines.

Protocols providing guidance to staff to ensure people taking medicines prescribed ‘as and when necessary’ (PRN) were being given them safely, were not always in place. Staff may not have been aware of the specific safe guidance for each medicine, such as the reasons why the medicine was prescribed, how many should be given at a time and how many tablets/liquid could be safely taken in a 24-hour period. There was a risk people may not be given their medicines when they needed it or could be at risk of taking too many placing their safety and health ant risk.

We found a tablet partly crushed on a person’s bedroom floor. The tablet was a painkiller. The tablets were signed as given at 7am. The person, who was not able to verbally communicate, was at risk of experiencing pain as they had not received the medicines as prescribed to control pain and would have been unable to tell staff.