CQC report explained · a nursing home
What the CQC found at Dolphin View Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, February 2024
Dolphin View Care Home is rated Requires Improvement; inspectors found safer medicines management and improved leadership, but gaps in risk assessments, care records and oversight remained.
This was an unannounced focused inspection on 16 and 17 January 2024. Inspectors spoke with people, relatives, staff and outside professionals. They observed care and checked care records, medicines records, training records and management systems.
The home was not always safe. Some risk assessments were missing or out of date, and some safety checks had not been recorded. Medicines management, staffing levels and activities had improved since the previous inspection.
Care planning was not always personal, complete or easy to read. Management systems had not consistently found or dealt with problems. The new home manager had improved staff morale and openness, but the home remained rated Requires Improvement for Safe, Responsive and Well-led.
Improved medicines management
Medicines administration and storage had improved. The manager carried out regular checks and acted when standards were not maintained.
“Medicines administration and storage had improved.” from the report
Improved staffing
Staffing levels were considered safe. The home had reduced its reliance on agency staff and sickness levels had reduced, helping with continuity of care.
“The provider had reduced its reliance on agency staff recently and sickness levels were low, meaning people received a better continuity of care.” from the report
Positive new leadership
People, relatives, staff and outside professionals described a calmer and more supportive culture under the new home manager.
“The atmosphere and morale was improved.” from the report
Activities had improved
The home offered a range of activities and had developed links with local organisations and groups.
“Activities planning and delivery had improved.” from the report
Incomplete risk assessments
seriousSome risk assessments were missing or not suitable to explain people's individual risks. Some necessary safety observations had also not been completed or recorded.
“Risk assessments were not always fit for purpose, for instance lacking person-centred information to enable staff to fully support people and reduce risks.” from the report
Weak governance and follow-up
seriousAudits identified some issues but actions were not always completed. The systems did not reliably identify and reduce risks to people's health and safety.
“Systems had not been established to effectively assess, monitor and mitigate risks to the health, safety and welfare of people using the service.” from the report
Care plans were not always clear
needs fixingCare records varied in quality, were not always updated promptly and did not always contain enough useful personal information.
“Records were not always updated promptly. They contained gaps and did not always contain enough useful person-centred information.” from the report
Limited staff support and learning
needs fixingStaff had not had regular supervision for over a year under the previous manager, and formal learning after incidents was not effective or consistent.
“Learning had not always been shared appropriately or embedded after incidents.” from the report
- 01How are you making sure every person's risk assessment is complete, personalised and kept up to date?
- 02How are safety observations recorded and checked, including checks linked to diabetes management?
- 03What action has been taken to improve care plans and make them easier to find and read?
- 04When will staff receive regular supervision, training and support for their roles?
- 05What progress has been made on the action plan for the Regulation 12 and Regulation 17 breaches?
This was a focused inspection of Safe, Responsive and Well-led only; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 7 February 2024 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.
What inspectors found, April 2023
Dolphin View Care Home is rated Requires Improvement; inspectors found kind care but serious medicines, staffing and management shortfalls.
This was an unannounced focused inspection on 13 and 14 February 2023. Inspectors spoke with people, relatives and staff, and checked care files, medicines records, recruitment files and management records.
The home was caring, and people said staff treated them kindly and with respect. Risks were assessed, infection control was satisfactory, and people felt safe. However, medicines records were not reliable enough to confirm that people received all their medicines as prescribed.
Staffing was sometimes below the agreed level. Activities did not always happen, and some care records were incomplete. The home’s checks had not found or fixed these problems quickly enough, and staff morale and confidence in management were poor.
The overall rating remains Requires Improvement. The home breached regulations on safe care and treatment and good governance. CQC required an action plan and will monitor progress with the provider and local authority.
Kind and respectful care
People and relatives described staff as kind and caring. Inspectors observed positive interactions and found that people’s privacy, dignity and independence were respected.
“People were treated with dignity, respect and equality by kind staff.” from the report
People felt safe
People said they felt safe, and staff understood their duty to report abuse or poor care. Individual risks had been assessed and safety measures were used.
“People felt safe and protected from the risk of abuse and harm.” from the report
Infection control and cleanliness
The home was clean and tidy. Inspectors were assured that infection prevention arrangements, protective equipment and visiting arrangements were suitable.
“At this inspection we found the recommendation had been addressed and the home was clean and tidy.” from the report
More involvement in decisions
People and relatives were involved in decisions about care and support. This was an improvement since the previous inspection.
“At this inspection we found the provider had acted on our recommendations and improvements had been made to ensure people were consulted and involved in decisions.” from the report
Medicines could not always be verified
seriousMedicine administration records were not always accurate or detailed. Records for creams and as-required medicines were also incomplete, creating a risk that medicines were not given as prescribed.
“We were unable to assure ourselves people had received all their medicines as prescribed.” from the report
Staffing and call bells
needs fixingStaff numbers sometimes fell below the agreed level, including during sickness. Inspectors also saw call bells ringing for longer than needed, and staff said management did not always help during shortages.
“There had been times when staff levels had fallen short, including in connection with sickness.” from the report
Activities were not reliable
needs fixingActivities had not always happened as planned. No stimulating activities took place during the inspection, and staff were often too busy with their main duties to provide them.
“However, activities had not always taken place as planned and during the inspection, no stimulating activities took place.” from the report
Weak management oversight
seriousAudits and checks had not identified or fixed problems with medicines and care records. Staff gave mixed feedback about morale and said the manager was not always approachable or visible.
“Governance systems were not robust.” from the report
- 01How are you now checking that every medicine, cream and as-required medicine is recorded correctly?
- 02What staffing level do you aim to have on each shift, and what happens when sickness means you are below that level?
- 03How often are activities now taking place, and how do you make sure people who prefer to stay in their rooms are offered suitable social contact?
- 04How are food and fluid charts and turning charts checked for completeness?
- 05What changes have been made to improve staff morale and make management more visible and approachable?
This was a focused inspection of Safe, Caring, Responsive and Well-led; Effective was not inspected and its previous rating was used to calculate the overall rating. This explanation was written from the published report of 6 April 2023 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 Dolphin View Care Home
6 rated inspections over 8 years: the service has slipped, from Good to Requires improvement.
- February 2024Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2023Requires improvementstayed Requires improvementSafe: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- July 2022Requires improvementSafe: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- February 2022Inspected but not ratedSafe: Inspected but not rated
- December 2018Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2017Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2015GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2020
Registered with the Care Quality Commission on 13 May 2020.
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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