Dovehaven Grove

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.

This is the first assessment for this service under the new provider. The service was rated good under the last provider. At this assessment, this key question has been rated good.

This meant leaders and the culture they created promoted high-quality, person-centred care. However, the service was in breach of legal regulation in relation to good governance.

This service scored 71 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement and understanding challenges and the needs of people living at the service.

The registered manager told us they were committed to making improvements at the service and acknowledged where improvements needed to be made.

Regular staff meetings were taking place and daily ‘flash’ meetings were being held, records of these included the topics discussed as well as the staff attending. Staff told us that the service’s core values are accessible to them on their company app.

The service sought feedback from and people. Positive feedback was seen in relation to the care they received and the management of the service. Staff feedback was sought which focussed on learning and improvement, and included a “you said, we did” document. Resident surveys were also completed. The results of these were on display in communal areas, which shared the actions they had taken as a result of the feedback. The provider undertook a staff survey during our inspection to obtain their views in relation to the support by the management.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and they embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was a registered manager in place, who told us they had an open-door policy and had worked hard at building good relations with staff and people.The registered manager told us that they received good support from the senior team.

The senior team visited the service regularly and the registered manager was being supported by the previous manager who was in a more senior role with the provider.

Staff and people living in the service told us the registered manager was easy to approach, supportive and listened to them. Staff comments included, “The (registered) manager is great, I can speak to her about anything.” Others said they could, “Catch up” with the registered manager, “Whenever we want through the day” and the registered manager was, “Very knowledgeable”.

Team meetings were being held with the staff team. Records included the dates of these, the staff attended and the topics discussed. Records confirmed the involvement of the staff team in these.

The provider fostered a positive culture where people felt they could speak up and that their voice would be heard.

Staff were given opportunities to discuss performance via supervision and appraisal processes. The registered manager told us they were working on plans to ensure an effective system was in place to provide staff with up to date and regular supervision.

Staff told us they could speak up about anything and were listened to, and that concerns raised would be acted on. Comments included, “I am aware of the term freedom to speak up, and (I would be) confident to do so if needed. I am aware of whistleblowing policies. All policies are kept in the staff room; there are regular staff meetings.” Staff spoke highly of the approachable manner of the registered manager. One staff member told us, “The (registered) manager is definitely approachable and knowledgeable.”

Most staff were aware of the homes whistleblowing policy and understood the various ways in which they could raise a concern. The service user guide and statement of purpose both contained information on how to raise a concern.

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.

Some, but not all staff that we spoke to told us they felt valued, that the culture at the service was good and the registered manager and provider promoted inclusion and equity in the workplace. Others staff told us examples of being supported with returning to work after leave and being supported with their mental wellbeing.

The service held a monthly culture and leadership workshop with the aim of promoting and supporting a positive culture at the home. Policies and guidance was available to ensure staff had access to information to support them in their roles.

A staff member told us that “There is a good culture here where everyone is given opportunities. They really promote diversity here and all staff are given the opportunity to grow.” We observed positive working relationships had been established at all levels. The management team were visible in the communal areas, and it was clear they knew people and staff well.

Feedback the provider had received from staff around the issue of pay and employee benefits had been acknowledged by the provider; employee benefits were under review and pay had been increased in response to this feedback.

The provider did not always have systems to support good governance and did not always act on the best information about risk, performance and outcomes.

The service had in place a range of quality monitoring tools, audits, systems and had processes which they used to monitor the service, identify areas of concern and drive improvements within the home. However, improvements were still needed as systems and processes were not always effective in identifying the concerns we found during this assessment.

Whilst care records were in place which contained information about people’s needs, not all the care records reviewed included up to date, current and consistent information in them. A care file audit undertaken by the management team had failed to identify gaps in staff files that we reviewed during our assessment. We found concerns in relation to staff files which did not confirm staff had been recruited safely and in line with guidance and one audit was incorrect in its findings. The service did not make sure medicines recordkeeping supported medicines administration to safely meet people’s individual needs, increasing the risk and potential for mistakes.

Daily walkarounds of the home (to check the safety of the service and the quality of the service) had not been carried out for some time. As a result of our assessment these were commenced by the management. However, when we checked the record of this on day 2 of our visit it failed to identify the concerns we found or offer assurance these concerns had been acted upon. We also noted that infection prevention control audits had not always identified the concerns that we noted during our assessment.

Although a good range of audits were undertaken by the service, it was not always evident what actions, if any, had been taken to address concerns identified, as these actions had not been signed off or dated as completed. The nominated individual told us the actions were being recorded on the full home action plan to support monitoring and oversight of the service. However, when we reviewed this record it did not identify some of the issues we identified during our assessment, and not all areas of the action plan had been reviewed since August 2025 and was only during our assessment.

Senior audits had been undertaken; records included a wide range of information and actions that were required as a result of these, but they did not include how the findings would be addressed. The nominated individual told us this information was included on the full home action plan. They said the actions from audits were recorded in this document. There was evidence that confirmed out of hours visits were being undertaken however, the times of these indicated that they were being completed during morning handover and not out of hours.

The registered manager told us that they were aware of several areas of governance that required improvement and that they were working hard to improve these areas.

The provider understood their duty to consult and work in partnership with other organisations so that services worked together to support people. They share information and learning with partners and collaborate for improvement.

The service reported a positive working relationship with the local GP practice. However, the management team discussed some difficulties that had experienced in relation to ensuring timely assessments of people’s needs were undertaken.

We received positive feedback from professionals who had visited the service who told us that they had witnessed kind, person centred care and that the service had worked with them to improve.

Staff told us people were supported to access the community and mentioned taking a person to attend a local Church and community activities. Representatives from the local Church also visited the service regularly to provide pastoral support. We saw members of the Church visiting during the assessment. They told us they, “Were invited by the home (service) to deliver mass to the residents (people who used the service). We come every week and deliver mass once a month.”

The registered manager told us how supporting people to engage with community activities and engagement was something they strongly wished to promote and encourage at the service.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. The provider had a range of policy, guidance and processes in place to support continuous learning and improvement at the service.

The registered manager and senior team reported that they had experienced some recent difficulties meeting the needs of people with behaviours that challenge. Despite this, some staff had received no training in positive behavioural support since 2021.

The provider had invested in the installation and use of Nobi sensor lights throughout the home to aid in the detection of movement in bedrooms, so that individuals at risk of falls could be responded to in a timely manner to reduce the risk of them experiencing a fall. The registered manager informed us that this has resulted in a reduction of falls occurring within the home. The Nobi sensor is an AI-powered (Artificial Intelligence) smart ceiling light system designed for elderly care, primarily to detect falls.

The provider had adopted an electronic pain identification tool which they used to assess people who may not be able to express their pain verbally.

Most staff spoken with said the management team would listen to and respond to any suggestions they put forward and would learn from and make improvements because of feedback received. However, 1 member of staff member was not confident that improvements would be made in the service.