Dovehaven Grove

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. This is the first assessment for this service under the new provider. The service was rated good under the last provider. This key question has been rated 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 infection prevention and control, management of medicines, safe environments and risks.

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 identify and embed good practice.

Most people and relatives told us they were supported to feel safe in the service. They said, “I walk with my frame because before I had it I kept falling, I feel a lot better now I got more used to it I can tell them if I am not happy”, “[Person] was made to feel safer” and, “I would be very happy to stay and I am much safer here than at home.” The staff we spoke with were able to discuss how they managed incidents and accidents. Staff comments included, “If a fall occurs and it is unwitnessed we would speak to the person in charge and call 111 or 999. We do body maps for everyone once a week to make sure we monitor for any unexplained injuries” and, “They have a service called IRS (incident reporting system), they inform them of falls, it is a 24-hour line and provide guidance on whether to call 999.”

We discussed the amount of incidents and accidents and falls with the management team who told us about the work they had been doing to manage these. They told us the amount of falls had been reducing and that incidents and accidents were thoroughly assessed with analysis and action plans to manage and reduce future risks. Detailed information in relation to incidents and accidents including lessons learned, reporting and actions was seen. There was a Datix (Incident reporting and risk management recording system) record detailing the incidents in the service and the progress of these.

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.

People told us they were supported with their needs. We observed professionals visiting during our visit to the service. There was evidence of the involvement of professionals and people accessing health services as required. Professionals were positive about the engagement of the service. Care records contained information about the involvement of professionals, admission assessments and checks on the admission of people was followed up by the management team to ensure it was completed. Staff told us the process for new admissions to the service to support safe transfers. One staff member said, “[Registered manager] or [Deputy registered manager] conducts the initial assessments and handover the information to senior (care staff). We discuss new admissions at handovers and at huddles (flash meetings).”

The registered manager told us they produced a document to be sent with people with a summary of their needs to support a safe transition of their care. We discussed recent challenges in the service and how people’s individual needs were being met and accessing the most appropriate service to meet people’s individual needs where placements had broken down.

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.

None of the people or relatives told us about any safegaurding concerns. “One person said, “I have every confidence in the home”, “I feel much safer here than at home” and, “The whole family are confident that this was the safest place for [person].” However, one person talked about situations where they experienced difficult relationships with some others living at the service.

Most staff knew what do to if they had safegaurding concerns and told us they had undertaken training. Staff said, “I have no concerns about abuse or neglect, I would follow the whistleblowing policy if I had concerns. The safeguarding policy is in the staff room” and, “I would report concerns to the seniors (care staff), then the management if seniors didn't act then senior management. If the management were not dealing with a concern I could report to CQC.”

Information in relation to safeguarding’s, including investigations, route cause analysis and actions were noted including lessons learned. The registered manager was completing a log that included a summary of the concerns. The registered manager explained this log was not being signed as completed by the registered manager as the audit trail and monitoring of these was included in the electronic monitoring system. A safegaurding policy was in place and up to date. However, this did not include the local authority safegaurding referral information and contact details, and there was no information in relation to the designated safegaurding lead. The registered manager gave assurances this would be addressed without delay.

The provider did not always work well with people to understand and manage risks.

We saw evidence of risk assessments in place in care records. However, we noted 1 person’s risk assessment in relation to their needs was conflicting in relation to falls risk and nutrition. The registered manager addressed this during the assessment.

We also observed 1 person mobilising around the service without the use of a walking aid and another without shoes. The registered manager told us it was people’s choices how they were mobilising. However, when we checked the records their choices in relation to mobilising and how to manage this safety was not recorded. This meant staff did not have access to up-to-date information in relation to individual choice and risks.

Contingency plans and business plans were in place with information and guidance to support the service in the event of an emergency situation.

No concerns were raised by people or relatives in relation to the management of people’s needs. Staff demonstrated an understanding of people’s needs and how to look after them. One staff member said, “It’s all about getting to know people individually and talking to them. Some techniques work better for others.”

Staff discussed a new system they had in place which supported the assessment of people’s pain who were unable to describe this to staff to support and enable appropriate care to people. Staff told us about the recent improvements in the service and care plans to ensure people’s individual behaviours were assessed and measures in place to manage risks.

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

Information and guidance was on display including an innovative electronic way accessible to anyone to report environmental faults and concerns. The management team told us there was ongoing refurbishment taking place. During our walkaround we saw some areas had recently been renovated including the quiet lounge, some bathrooms and murals with pictures from the local areas were on the walls on both units. However, not all areas of the environment were safe. The linen rooms on both floors were left unlocked, people’s personal items required storing safely in some bedrooms and store rooms and some actions were required to repair radiators covers and paint work. We noted a number of mattresses were overhanging which posed a safety risk. The management team had not identified this concern but, the provider took action and replaced all the mattress’s that required changing following our walkaround.

The management team told us about the improvements that had been done. Servicing and externals checks were ongoing; however, some environmental audits and checks did not pick up on some of the findings we found at this assessment, and where we saw findings were recorded in the checks there was not always confirmation that these have been acted upon.

No concerns in relation to the environment were raised by people. People told us they felt safe in the service. One person said, “I like my room I have a buzzer over my bed, and it makes me feel safe.” Relatives talked about their confidence that Dovehaven Grove was the safest place for their family member to live. One relative said, “We feel at ease that [person] was safe, and the staff are well trained in moving and handling.” Another person said, “I would be very happy to stay, and I am much safer here than at home.” Staff were seen using moving and handling equipment safely and relatives discussed the ways in which the service monitored people such as Nobi lights (Nobi Smart Lights use sensors forreal-time fall detection) to keep them safe. Doors were seen secured safely.

Records we reviewed confirmed that fire safety checks had been done, and PEEPs (Personal Emergency Evacuation Plans) were in place, along with an emergency grab bag to use in the event of an emergency. External fire risk assessments had been completed to support fire safety. The management team provided an up-to-date copy of the fire risk assessment that confirmed the actions required as a result of the assessment had been completed.

The provider made sure there were enough qualified, and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs. However, further improvements were required to improve the training undertaken by the staff team.

Duty rotas were in place which identified the staff on duty for the shift and a dependency tool was being completed that identified the numbers of staff required to support the individual needs of people. We saw some staff had reasonable adjustments to their workings hours; however, this was not always the case. The management team told us they had an ongoing recruitment drive, and they used agency staff to cover shortfalls in staffing numbers, and they used the same agency staff where possible. There was an agency profile file, but this was incomplete and did not confirm that agency staff had undertaken an induction to the service on their first shift. We observed plenty of staff supporting people’s needs and nurse call bells were answered promptly during both days we visited the service.

We saw a record with dates of the supervision and 1:1 being undertaken, this showed these had been undertaken by a range of staff roles. A training matrix was in place; however, this identified some gaps in the training of the staff. The management team provided details of recent basic life support training undertaken by some staff during our assessment. We saw evidence that most staff had undertaken learning disability and autism training however, the record of PBS (Positive Behaviour Support) training identified this had not been completed since 2021.

The staff files we checked did not always demonstrate safe recruitment had been undertaken. Not all records contained completed interview notes in them. The management team had completed a care file audit recently which did not identify gaps in the staff files reviewed. However, we saw that one of the records they checked was not complete. Records of monitoring and checks could not be relied upon to ensure staff files were complete and correct.

People and relatives were complimentary about the staff and their skills, but some said there was sometimes not enough staff. Comments included, “There’s always someone around if you need them, but they haven’t much time they’re always busy dashing to the next person”, “I can speak well of all the staff but there’s not enough of them sometimes. The staff are all well trained they are always going on courses” and, “Theres always plenty of staff and even at night.”

Staff confirmed training had been undertaken and discussed their recruitment process. Some staff discussed some concerns in relation to the quality of the training they received, how often they received supervision and whether they had all completed an induction on commencement to their role. They told us, “There are enough staff. Not a heavy reliance on agency staff. When I first started it was nearly all agency staff”, “We have done face to face courses like fire, moving and handling. Other courses are online, the training is really good here” and, “The quality of online training is “okay”. Moving and handling training was delivered face 2 face. I have done a lot of online training.” Two staff told us they had received no formal induction as such but did shadow another staff member for 2 to 3 weeks.

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.

Not all people and relatives told us the service was clean. One person told us they felt the service was clean and tidy. They said, “The home (service) is kept clean and tidy.” We saw some feedback from a relative about the cleanliness of a person’s bedroom. Staff told us they had access to personal protective equipment (PPE) and undertake cleaning tasks. They said, “There is enough PPE, staff wear it as needed” and, “I check with [people] that it is okay to enter their room and carry out cleaning tasks etc.” Staff were able to describe the process for safe hand hygiene and using PPE correctly.

Information and guidance was on display about hand hygiene and PPE in communal areas of the service. Staff had access to handwashing facilities and hand gel dispensers. We observed plentiful supplies of PPE available to staff, and this was being worn as needed by the staff team. However, we noted that PPE was not always being stored appropriately or safely, some cupboards with PPE were left unlocked and one storage room had loose face masks.

We saw a number of areas required cleaning and posed an infection risk. These included, some people’s bedrooms, marking on a communal sink, a shower chair that was unclean and appeared rusty, one person’s walking frame was stained in the dining room and the sealant on the flooring to some communal bathrooms was dirty. A record in relation to bathroom checks did not identify the findings we saw at our assessment.

Whilst the sluice rooms were locked we noted these were dirty and equipment was being stored inappropriately. Personal items were noted along with cleaning products and housekeeping trolleys, and the housekeeping buckets were not stored safely. We discussed this with the management team who gave assurances that they would address the concerns during the assessment. The registered manager told us they had completed a full walkaround and recorded all areas of concern had been addressed. However, when we checked concerns were still noted. The concerns we found had not been identified on the walk around records completed on the day. Records were being completed by housekeeping staff. However, these were not being completed every day. There was evidence of infection control audits with actions recorded from the findings, however, these had not been signed off to confirm they had been reviewed or action taken on the findings. We could not be assured that all areas of the service were being cleaned and monitored as required.

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. Medicines to the service were supplied by several pharmacies. There were good processes in place to obtain medicines, advice, and information on stock availability so that any issues could be resolved promptly to ensure that people received their medicines. There were also arrangements in place to obtain advice during out of hours.

Medicines, including controlled drugs, were stored securely, well organised and in date, however, there were some discrepancies in stock counts and controlled drugs records were not always completed correctly. Temperature monitoring of areas where medicines were stored were recorded, although there were some inaccuracies and missed entries.

Electronic Medication Administration Records (eMAR) were available to support and record the administration of medicines, however these did not always provide sufficient information to ensure the safe administration of medicines in accordance with manufacturers guidelines, and some entries had conflicting information to care plans and prescribing information. This meant there was a risk of people receiving their medicines incorrectly which put them at risk of harm.

PRN protocols (for medicines that are taken ‘when required’) were not always in place for PRN medicines and those available did not always give sufficient information to support the administration of medicines with a variable dose. This meant there was a risk of people not receiving their medicine as intended and their conditions not being managed effectively.

Topical MARs (tMARs) were available for the administration of medicines applied to the body; however, they did not always have sufficient details of where topical emollients were to be applied. Where patches had been applied, patch rotation charts were used, however, there was no system in place to monitor these patch applications were still in place between administrations. This meant there was a risk of people not receiving their medicine as intended which put them at risk of harm.

Care plans were not always in place or accurate for people with specific conditions to inform care givers of how to manage these. We found that some time sensitive medicines were administered late, which put people at risk of their conditions not being managed effectively.

The use of thickener was recorded consistently in people’s records. Staff had good knowledge of people’s needs and for one person who required their medication to be given covertly, staff knew how to do this. The supporting information of how to give the medicines covertly, however, was not documented in the care records or eMAR. This meant there was a risk of people receiving their medicines incorrectly which put them at risk of harm.

Some staff had not completed the online training to the level required by the service provider and workshops were overdue for some staff members who required it. These are required by the service provider to be completed annually. This did not provide assurances that staff administering medicines were competent to do so.

Weekly and monthly audits on medicines were completed regularly; however, they had not been effective at identifying the issues found at this assessment.