CQC report explained · a residential care home
What the CQC found at Dove Lane
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Staffing was not safe at certain times. People, including those living with epilepsy, could be left without support while staff helped others with personal care.
- Effective?
- Requires improvement
- Care, food, training and healthcare support were generally suitable, but some doorways were too narrow for wheelchair users and the home could not fully show that best practice guidance was being followed.
- Caring?
- Good
- Staff knew people well, treated them with kindness, respected their privacy and dignity, and supported day-to-day choices and independence.
- Responsive?
- Requires improvement
- Low staffing meant people could not always leave the home, follow social interests or have their personal preferences met. Staff did understand people’s likes and dislikes and supported contact with family and friends.
- Well-led?
- Requires improvement
- The manager and provider were positive about improving care, but their audits had not identified the effect of staffing shortages on people’s daily lives or the failure to follow relevant guidance.
What inspectors found, January 2022
Creative Support - Dove Lane is rated Requires Improvement; inspectors found kind care, but staffing levels put people at risk and limited their activities.
The inspection took place on 8 December 2021. One inspector spoke with four relatives and six staff, observed care, and reviewed care, medicines, recruitment and management records.
The main concern was staffing. At some times, only two staff were working when people needed two staff for personal care. This meant other people could be left without support, including people living with epilepsy.
People were treated with kindness and supported with medicines, food, healthcare and communication. However, low staffing meant people could not always go out or follow their interests. The home’s checks had not identified these problems.
The overall rating is Requires Improvement. Safe, Effective, Responsive and Well-led were also rated Requires Improvement. Caring was rated Good. The previous Good ratings had deteriorated since the last inspection under a different provider.
Kind and respectful care
Staff knew people as individuals and treated them with kindness, compassion, privacy and dignity.
“We observed staff speaking with people in a kind and compassionate way.” from the report
Medicines and infection control
Staff were trained and checked as competent to give medicines. The home was clean and infection control arrangements, including PPE, were in place.
“Staff were trained to support people safely with their medicines and had their competency checked to do so regularly.” from the report
Health and dietary support
People were supported with their dietary needs and to see health professionals. Staff followed professional advice and kept health information available for hospital staff.
“People were supported to see health professionals such as GP's, dentists and speech and language therapists if they needed this support.” from the report
Communication and choice
Staff used methods that made sense to people, such as objects, signs, eye contact and touch. People were offered choices in daily life.
“People were offered choices in their day to day lives such as what to wear, what to eat and drink and how to spend time in their home.” from the report
Family involvement
Relatives were asked for feedback and were involved in reviews and care discussions. Complaints information was available and concerns were followed up.
“People and their relatives were asked for feedback about their care and support.” from the report
Unsafe staffing levels
seriousAt certain times, two staff were not enough to support people safely. This meant people could be left alone or without the close support required by their risk assessments.
“There were not enough staff to support people safely. This put people at risk of harm.” from the report
Missed activities and outings
needs fixingPeople could not always leave the home or follow their chosen interests because staff were busy with personal care, cooking and cleaning. One person had not gone for a walk in over four weeks.
“One person had leaving the service to go for a walk noted as a preferred past time in their care plan. This person had not left the service in over four weeks.” from the report
Access for wheelchair users
needs fixingSome doorframes were too narrow for wheelchair users to use easily. People could not access the laundry room, limiting their independence.
“People using wheelchairs were unable to access the laundry room due to the size of the doorframes.” from the report
Checks missed important problems
needs fixingAudits identified some health, safety and medicines improvements, but did not identify the lack of activities and the effect of staffing on people’s daily experience.
“Audits had not been effective at picking up on the issues we found at this inspection, in areas such as people having limited opportunities to follow preferred social interests and past times.” from the report
- 01How many staff will be on duty during the times when people need two staff for personal care?
- 02How will you keep people with epilepsy safely supervised when staff are supporting someone else?
- 03How often can each person go out and take part in their preferred activities, and what happens if staffing levels are low?
- 04What progress has been made on widening the doorframes for people who use wheelchairs?
- 05What action has been taken since the inspection to address the three breaches and improve staffing?
This inspection looked at the overall quality of the care home, including its premises and care, and assessed all five CQC questions. This explanation was written from the published report of 25 January 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Dove Lane
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- January 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- February 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2019
Registered with the Care Quality Commission on 30 April 2019.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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