Dover House

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 inadequate. This meant there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

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

This service scored 36 (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 clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

Evidence of a shared direction and culture was limited. People and relatives had raised concerns, and incidents had occurred that were not investigated and responded to fully. Lessons had not been learnt and cascaded to staff to prevent the same concerns and incidents repeating. There were no records of regular staff meetings to evidence engagement with staff to share the provider’s expectations and priorities and how to achieve continuous improvement . The provider’s Statement of Purpose stated as an aim of the service, ‘The service has been established with a quality-orientated approach to the business and a high degree of quality awareness is developed through all levels of staff training and management. The aim of these measures is to continually improve the quality of the service offered to our clients’. The provider had failed to achieve this aim.

The provider did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively, and they did not do so with integrity, openness and honesty.

We received positive feedback from staff in relation to the registered manager and the support they received. They had been in post for 4 months at the time of the assessment and acknowledged there was a lot of work to do to improve the quality and safety of care.
The senior staff with a responsibility for the day to day running of the service lacked the skill and ability to lead the team to provide safe and good quality care. This was evident by the numbers of issues and concerns found during the assessment. Not everyone living at the service had access to good quality care and standards had not been upheld. Staff had not been led by a competent leadership team who led by example.
The registered manager told us there was a lack of confidence among some senior staff and leaders, leading to poor judgment and decision making. However, this had impacted significantly on people’s care and treatment and had not been identified and action taken to improve staff abilities by the senior management team, including the provider.

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

Staff told us they knew how to speak up and who to. They were clear they would raise concerns if they had them and they would be listened to. However, the significant issues we found, including the poor environment some people were living in, and repeated safety incidents evidenced staff had not spoken up to keep people safe. Some staff were unable to tell us who they would report concerns to outside of the service, such as the local authority or CQC.
Relatives provided examples where they had raised concerns and felt they were not listened to, for example, the smell of urine, cleanliness, falls and unexplained bruising. We found these examples were ongoing issues that had not been improved on, so their voices had not been heard.

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.

There was an Equality, Diversity and Inclusion policy that sought to provide a diverse workforce. The majority of staff were recruited from abroad and did not match the ethnic background of most people living at Dover House. However, this did not appear to adversely affect the care people received and staff interacted well with people when they had time. People and their relatives did not raise any concerns in relation to cultural differences with staff. Some relatives said there was a language barrier with some staff, but they did not see this as a specific concern.
Staff said they were treated well and very happy in their role and with the support they received.

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

The provider did not have a clear oversight of quality and risk in the service which contributed to people being at risk of avoidable harm and of continuing to receive poor quality care. The provider’s systems to monitor and improve the safety and quality of care provision were not effective. Monitoring and auditing processes were unsuccessful in picking up issues within the service, or in taking action when issues were found.
We found there had been limited identification, assessment or mitigation of individual risks. Staff did not always have guidance in how to manage people’s risks when providing their care. Although incidents were recorded, this was inconsistent and some incidents were missed. The failure to effectively monitor accidents and incidents meant incidents were recurring and risks were not prevented. A culture of learning lessons through robust monitoring and taking immediate actions to improve was not in place, meaning improvements that could have been made had not prior to the inspection.

The environment some people were living in was poor with a pungent smell of stale urine and unclean conditions throughout floors 1 and 2. This had been picked up by audits undertaken by the registered manager in May 2025 and 4 subsequent months, and the provider’s compliance audit in September 2025 and the following 2 months. However, no action had been taken to ensure improvements were made. People continued to live in poor conditions.

The provider’s governance systems failed to identify there were insufficient staff deployed to meet people’s needs overnight. They failed to identify the shortage of staff skills throughout the day and night to make sure staff had the skills and confidence to meet people’s needs, such as peoples frustrated and distressed behaviour, wound care and the prevention of infection. Action had not been taken to ensure sufficient staff were deployed during mealtimes, so people had a fully supported, dignified and good quality mealtime experience.

People did not always have the opportunity to spend a day of meaningful activity and relaxation. The lack of meaningful activity had been noted in the provider’s compliance audits, however action had not been taken to improve this area of people’s lives.

Ineffective monitoring and governance systems meant the provider had significantly failed to identify or taken action to ensure people received safe and good quality care.

The provider did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people. They did not always share information and learning with partners or collaborate for improvement.

The provider did not always promote working collaboratively and ensure staff supported people following guidance and support by healthcare professionals and partners. Health and social care partners had identified safety and quality of care issues prior to the inspection and shared these, including wound care, infection control and the environment.

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

A learning culture was not embraced to ensure safety was a priority. Accidents and incidents were not effectively monitored to learn lessons to prevent further occurrences. Safeguarding referrals were not always made in line with local safeguarding protocols, and this had not been identified by the provider. The provider’s inadequate response to learning lessons from recurring incidents, and concerns and complaints received led to a lack of action taken to improve outcomes for people, leading to ongoing risk to people in their care. The provider did not act to improve the service until we raised concerns with them about our findings during the assessment.