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Inspection Summary

Overall summary & rating

Requires improvement

Updated 26 June 2018

Dalvey House is a care home that does not provide nursing care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service is registered to accommodate19 people. At the time of this inspection there were 16 people were living at the home, the majority of whom were accommodated for frailty of old age. An extension and building work were in progress at the time of the inspection.

There was no registered manager in post when we carried out this inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The previous manager ceased working at Dalvey House in the summer of last year. The service was managed by interim management arrangements until the appointment of the new manager in January 2018. This person was in the process of registering to become manager of the home when we carried out this inspection.

The last inspection was carried out 13 November 2015 and was rated as ‘Good’.

The inspection was unannounced and took place on 11 and 14 May 2018 and was carried out by one inspector on both days of the inspection.

Staffing levels were meeting people’s needs; however, the staff were stretched at times, there was high use of agency staff, which could affect the consistency of staff for people and the morale of the staff team.

The manager had systems in place to maintain and promote safety in the home. Environmental risks had been identified and action taken where appropriate. The delivery of people’s care had also been risk assessed to make this as safe for people as possible. The manager agreed to review record keeping so maximise the effectiveness of monitoring when this was needed and also to ensure that people’s dignity was maintained.

The care planning format was being reviewed and care plans were being re-written. At the time of inspection the plans were not all standardised so that it was difficult to find information.

Staff were recruited in line with robust policies and all the necessary checks had been carried out by close of the inspection.

Medicines were well-managed and people received their medicines as prescribed by their doctor.

Staff had received training in safeguarding and were aware of their responsibility to report concerns.

Staff were supported through indirect and formal supervision as well as an annual performance review.

The home was working collaboratively with health services so that people’s needs were met.

People’s consent was sought and granted with regards to the way they were cared for and supported. Where people could not make specific decisions because they lacked mental capacity, staff were following The Mental Capacity Act 2005 and any decisions made in people’s best interest.

The home provided a good standard of food with people having choice of what they wanted to eat and their individual needs catered for.

Staff were kind, caring and compassionate in their interactions with people.

There was a programme of activities to keep people occupied; however, this could be improved as the activities co-ordinator only worked for two days a week. The manager was trying to recruit an additional person for this role.

Complaints were responded to and the procedure was well-publicised.

Since the last inspection, the registered manager had ceased working at the home and a new manager appointed.

There were auditing and monitoring systems being followed seeking overall improvement.

Inspection areas


Requires improvement

Updated 26 June 2018

The service was safe.

There were enough staff, although the team was stretched because of staff vacancies and high use of agency staff.

Medicines were managed safely.

Risks were assessed and action was taken to reduce or manage any identified hazards.

Systems were in place to protect people from harm and abuse. Staff knew how to recognise and report any concerns.

Staff were recruited although some records were not in place at the start of the inspection.



Updated 26 June 2018

The service was effective

Staff received induction and on-going training to ensure that they were competent and could meet people’s needs effectively.

Supervision processes were in place to monitor performance and provide support.

The service was meeting the requirements of the Mental Capacity Act 2005.

People’s dietary and nutritional needs were being met.



Updated 26 June 2018

The service was caring.

People had good relationships with staff.

Staff respected people’s choices and supported them to maintain their privacy and dignity.


Requires improvement

Updated 26 June 2018

The service was responsive.

People received personalised care but care plans were in need of improvement to ensure staff were informed and could deliver consistent care.

Activities were provided but more could be offered to keep people meaningfully occupied.

There was a well-publicised complaints procedure and complaints were responded to appropriately.



Updated 26 June 2018

The service was well-led.

A new manager had been appointed and seeking improvements after a period on interim management.

There was a positive, open culture.

There were systems in place to monitor the safety of the service provided to people.