Dorset 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 remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (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.

Staff understood the process for reporting and recording events. Events were reviewed regularly by the registered manager and the provider. This enabled them to analyse themes, trends, and patterns, understand why events happened, and identify lessons learned to prevent them from happening again. Any learning was shared with staff. For example, through the provider’s 'lessons learnt: preventing, protecting and continuously improving' bulletin.

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.

Staff worked closely with other healthcare professionals. Appropriate referrals were made to other services such as GP’s and speech and language therapists (SALT). Staff were proactive in escalating concerns and sharing information about changes in people’s health. This enabled timely input and intervention, such as discussions with advanced nurse practitioners (ANPs) during their rounds at the home. Staff followed guidance and direction provided from external professionals. Care plans were updated when people's needs changed to accurately reflect current support.

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 told us they felt safe living at Dorset House. One person said, “I’m now settled into living here, last thing in the world I wanted to do.” Another person said, “It is perfection itself.”

Staff received safeguarding training. They knew how to protect people from abuse and who they would report any concerns to. One staff member said, “If I had any concerns, I would go the manager or clinical lead. If there is any abuse it needs to be reported. If it was the weekend I would go the nurse in charge.” The registered manager shared concerns appropriately by following the correct process and ensuring these were reported to the relevant agencies. Systems were in place for people who lacked capacity to consent and were deprived of their liberty under the Deprivation of Liberty Safeguards (DoLS). These systems ensured restrictions were lawfully authorised. Any authorised restrictions were properly assessed and accurately recorded in people's care plans.

The provider 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.

Staff knew how to keep people safe and were knowledgeable about the risks people faced and how best to mitigate these. For example, staff managed risks associated with eating and drinking, and falls. We also observed staff supporting people to use equipment, such as hoists, safely.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Although window restrictors were fitted in most areas, we identified some exceptions where they were missing, presenting a potential safety risk. Also, the restrictors in place were not fitted with tamper-proof screws. This meant there was a risk the safety mechanism could be easily removed or disengaged by people. We raised this with the management team who acted immediately and by our second visit all screws had been replaced with tamper-proof fittings. In addition, the management team had also communicated this issue across all the providers services by sending an email to all the maintenance operatives and managers in the group requesting a responsive audit be undertaken to ensure compliance with legal requirements. We also identified 1 exposed hot pipe in a person’s ensuite bathroom. Immediate action was taken on the day of the inspection by isolating the radiator to eliminate any safety risks. The following day, the exposed pipe was fitted with an appropriate protective covering to prevent direct contact with hot surfaces. This corrective action and ongoing safety awareness were also discussed with staff during the daily huddle.

The dementia floor lacked sufficient signage to support people to find their way around. However, the initial procurement process for signage was delayed due to the original supplier ceased trading, a replacement order has since been secured with an alternative provider.

The provider had an up-to-date fire risk assessment. All staff had received fire safety training. Fire drills and alarm tests were conducted. Personal emergency evacuation plans (PEEPs) were in place, accessible, reflected people’s individual needs, and provided clear guidance for staff. Equipment and appliances were regularly serviced and checked to ensure it was serviceable and safe to use.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People told us there were enough staff. One person said, “The staff are good, they can vary but mostly excellent, work really hard. Anything you need and if you’re upset, they’ll look after you.” A relative told us, ““There are enough staff for us.”

The provider had a training matrix in place which evidenced staff had completed statutory and mandatory training and competency assessments. Training requirements depended on the staff roles. For example, all staff regardless of role completed training in areas such as safeguarding, fire safety, equality and diversity, dementia and learning disability. Nurses and managers completed additional training in other areas such as medication management and drug calculation. This meant staff were able to meet people’s individual needs. The provider’s recruitment, disciplinary, and capability processes were fair, transparent, and regularly reviewed to ensure there was fair recruitment. The provider followed safe recruitment practices which ensured staff were of a good character to support vulnerable people. This included Disclosure and Barring Service (DBS) checks. DBS provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There were some areas of the home which required some attention through general wear and tear. The provider had already identified this, and there was a refurbishment plan in place. We also identified some crash mats which were ripped. Ripped crash mats compromise the fluid barrier required to maintain a hygienic, cleanable environment. We raised this with the management team who confirmed damaged ones were discarded of and replaced. The ones we saw were replaced promptly and staff were reminded to review fixtures and fittings as part of the daily walk rounds which occur.

No one we spoke with raised any concerns in relation to infection prevention and control.The provider carried out infection prevention and control (IPC) audits and staff attended IPC training.

The home had a food hygiene inspection and was rated 5 star by the local authority’s environmental health team. This meant food hygiene standards were very good and fully comply with the law.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People did not raise any concerns in relation to medicines. We did identify topical creams were not always dated when opened. PRN ‘as and when required’ medicine protocols were in place and provided clear guidance on when to administer them. These protocols could be further strengthened by including alternative strategies to use before administering medication. However, the recording of PRN effectiveness was clear, with outcomes clearly documented.

Processes were in place for ordering, storing, and disposing of medicines. Following our onsite visit, we were sent written testimonials professionals had completed about the service. One professional who worked closely with the service said, “I have had the pleasure of working with Dorset House Nursing Home for the past six and a half years. The standard of medication storage, ordering and processes are excellent.” The clinical room and drug fridge temperatures were checked daily and remained within safe limits. No longer required medicines were dual-signed and logged in the register. Controlled drugs, (CDs), which are subject to higher levels of legislation for monitoring were recorded accurately, clearly, and audited weekly. Where people received medicines covertly (hidden in food or drink), appropriate supporting documentation was in place.

Where people were prescribed transdermal patch application these were recorded on a body map, and any intermittent replacement were clearly indicated on the MAR chart, with daily confirmation patches remained in position. Staff who administered medicines were fully trained and had their competency regularly assessed. We saw medication reviews had been carried out for antipsychotic medication by the advanced nurse practitioner (ANP) and mental health team. Bimonthly medication audits were carried out and where discrepancies were noted these were investigated to identify the cause and any actions needed. For example, an audit completed on 22/05/2026 highlighted that improvements were required regarding the documentation of medication refusals.