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 inadequate. 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 the safe management of people’s medicines and the maintenance and management of the premises and environment.

This service scored 56 (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 proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

At our last inspection, incidents of distressed behaviour were not consistently managed, and risks were not always recognised or mitigated. During this inspection we found the provider had introduced individualised risk assessments, positive behaviour support plans and enhanced incident oversight. Incidents were reviewed by the management team, and learning was shared through monthly lessons learnt bulletins. We saw evidence that incidents of distressed behaviour had reduced for some people following implementation of revised care planning and staff training.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There was now a more robust approach to people’s safety and how this was managed. Individual risk assessments were adequately assessed and reviewed. This meant information passed to other agencies such as hospitals and other care homes were up to date and reflected the needs of the person. People who were unwell and moving between services could be assured their records were sufficient to ensure their needs could be met. Staff who did not know them would have the information to provide care and support because their needs and risks were adequately recorded and shared.
People had been referred to healthcare agencies such as GP, dietician, podiatrist and community mental health team. The provider and registered manager had engaged closely with health and social care staff at all levels and supported moves to different services where it was necessary following assessment of people’s needs.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People were protected from the risk of abuse and improper treatment. At our last inspection, incidents were not always appropriately referred to the local authority as a safeguarding concern. This meant people’s safety could not be assured. The provider now responded appropriately to safeguarding concerns and made referrals to the local authority when necessary. Incident investigations were completed and reviewed by managers and learning shared with staff. Relatives generally told us they felt people were safe. Comments included, “I don’t have any concerns about safety. There are always lots of staff around and they smile and create a nice atmosphere”; “They are able to keep him safe because he has 1:1 care for 12 hours a day” and “I think (relative) is physically safe in the home.”
Some people continued to express concerns regarding the impact caused by the distress of other people. However, evidence showed the provider had acted, including revising risk assessments, implementing behaviour support plans and relocating some people to more appropriate environments.
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.

The provider had not always worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

At our previous inspection we found risks to people's health, safety and welfare had not always been identified and staff did not have sufficient guidance to reduce risks. During this inspection we reviewed a range of care plans and risk assessments and found substantial improvement. People had detailed assessments including areas such as falls, choking, nutrition, skin integrity, distressed behaviour, continence and mobility. Care plans contained clear guidance for staff and identified personal triggers, preferences and support strategies. Relatives told us people were generally safer and risk management had improved, “It’s much better now they have been moved to another floor which is much quieter and safer for (relative).” However, some records still contained inconsistencies, and not all individual risks had been identified. Further work was required to ensure all documentation was accurate and consistently linked to care planning.

The provider was not always aware of all potential risks in the care environment and did not always control them. They did not always make sure the facilities and environment supported the delivery of safe care.

At our last inspection we found widespread concerns regarding the environment, including damaged flooring and furniture, poor standards of cleanliness and environmental risks. During this inspection significant improvements had been made. Most communal flooring had been replaced, communal areas were cleaner, damaged equipment had been replaced and ongoing refurbishment was continuing. A comprehensive service improvement plan was in place and had been used to drive the improvements. This work was ongoing and there continued to be many outstanding works and actions. However, we identified some people’s bedrooms and bathrooms had strong odours of urine. Relatives also continued to raise concerns regarding unpleasant smells and environmental standards in parts of the home. A relative said, “Quite often their personal room is not kept very clean. The floor is regularly dirty and could benefit from cleaning. The bathroom still has an odour.” The provider and registered manager were not aware of the extent of these concerns until they were highlighted during inspection. Whilst the environment had improved considerably, further work was required to ensure all areas were maintained to a standard that promoted people's comfort and dignity.

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

Staffing levels had improved significantly since the previous inspection, when there were significant issues relating to staffing levels and staff knowledge and skills. Occupancy had reduced, so agency staff were no longer routinely required and relatives observed more staff being available. Staff told inspectors they felt supported and had received additional training, including face to face training. Nurses had been supported through upskilling programmes to boost skills and confidence. Not all staff had completed annual refresher training when they should, so their training was out of date. The registered manager was taking action with staff to improve this.
Relatives whose loved ones received support through consistent staffing arrangements, particularly 1:1 support packages, described positive outcomes and good staff understanding of their individual needs. However, some relatives continued to raise concerns regarding communication skills, confidence, experience and staff recognition of deteriorating health conditions. Relatives said, “I think there are less people living in the home since the last inspection, so the staff ratio is probably better, but I don’t know if this has improved the care. Carers communication with residents is sometimes very limited and not clear”; “I think the basic care staff are literally trained in very basic tasks, which they complete as per a computer care plan. They do not seem to have much initiative or be able to deviate from what the computer says they should do” and “He has 1:1 care and the carers are excellent with him. The staff do seem to be experienced and understand how to deal with people with his condition.”

The provider generally assessed and managed the risk of infection and detected and controlled the risk of it spreading.

At our previous inspection we identified significant infection prevention and control (IPC) concerns. During this inspection, IPC standards had improved significantly. Flooring replacement and environmental improvements had reduced previous risks. Wound care management had improved, and we no longer found the serious concerns identified previously. Domestic staff now demonstrated awareness of known risk areas and cleaning schedules. However, odours remained in some areas, and some areas continued to have a residue on surfaces, so further improvements were still required. Some relatives told us the cleanliness of the environment was still of some concern. Comments included, “The home is generally cleaner and does not smell offensive anymore. Despite being cleaned the floors often look dirty and people do walk around with no socks on, which is concerning. The bathroom does smell quite badly despite regular cleaning” and “Cleanliness of bathrooms is still a weak point, and toilet areas do often still smell. I have had to ask for the toilet to be cleaned when I have visited as the odour is spreading into the bedroom.”

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

Medicines were still not managed safely. We identified multiple discrepancies between recorded stock balances and medicines remaining in stock. There was no assurance people had received their medicines as prescribed. The discrepancies were widespread, there was no assurance people had received their medicines as prescribed. The discrepancies had not been identified through existing audit processes creating a risk people’s health and well-being could be affected and the cause not linked. This was an ongoing issue since the last inspection. Improvements had been made regarding covert medicines processes and associated paperwork to make sure people received their medicines safely and lawfully. However, medicines governance arrangements were not sufficiently robust to provide assurance medicines were consistently managed safely and the importance of safe medicines administration was understood by staff. Some relatives reported no concerns regarding medicines management; nevertheless, inspection evidence demonstrated continuing shortfalls requiring improvement.