CQC report explained · a residential care home
What the CQC found at Dove House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks, medicines and infection control were managed safely, although some fire-safety works were still planned and staff vacancies were putting pressure on the team.
- Effective?
- Good
- This key question was not inspected in detail during this focused inspection. Its rating was carried forward from the previous inspection.
- Caring?
- Good
- Inspectors observed kindness and compassion, and relatives described person-centred care. However, the judgement was limited because Caring was not part of this focused inspection.
- Responsive?
- Good
- This key question was not inspected in detail during this focused inspection. Its rating was carried forward from the previous inspection.
- Well-led?
- Good
- The manager and staff created a positive, open culture. Governance systems, audits, records and communication with families had improved.
What inspectors found, November 2022
Dove House was rated Good; inspectors found safer systems and better leadership, but noted pressure from staff vacancies and some fire-safety work still to complete.
This was an unannounced focused inspection on 3 and 4 October 2022. One inspector and one medicines inspector spoke with people, staff, relatives and a healthcare professional. They checked medicines, care records, risk assessments, staffing, recruitment and quality checks.
The home was rated Good overall, and Good for Safe and Well-led. Inspectors found that people were protected from abuse, risks were assessed, medicines were managed safely and infection-control measures were in place. Staff knew people well and supported them using the least restrictive approaches.
The inspection found improvements since the previous rating of Requires improvement, published in January 2020. The previous breach of Regulation 17 was no longer in place. Because this inspection only looked closely at Safe and Well-led, the other ratings were carried forward from the earlier inspection.
Safe medicines
Medicines were stored securely, given as prescribed and recorded correctly. Inspectors found no gaps in the medicine administration records they checked.
“There were no gaps in the MARs we reviewed which provided assurance medicines were being given as prescribed.” from the report
Staff knew people well
Staff understood people's communication, preferences and behaviour support needs. They used proactive and least restrictive approaches to reduce distress and risk.
“People were kept safe from avoidable harm because staff knew them well and understood how to protect them from abuse.” from the report
Positive leadership
The manager was visible and worked directly with people and staff. Relatives and staff described supportive leadership and good communication.
“There was strong, visible leadership. The registered manager was observed to work directly with people.” from the report
Improved oversight
Quality checks, audits and incident reviews were being used to identify and make improvements. The previous governance breach had been resolved.
“At this inspection we found enough improvements had been made and the provider was no longer in breach of Regulation 17.” from the report
Fire-safety work
needs fixingA recent fire-safety report required work to be completed to protect people in a fire. The provider had a plan to address the issues, but the report does not confirm that all work was finished.
“The fire department had just issued the provider with a fire safety report, which required some works were undertaken to ensure people's safety in the event of a fire.” from the report
Staff vacancies
needs fixingThere was pressure on staff because of vacancies and changes in one person's needs. Vacancies were being covered by agency, bank and overtime staff while recruitment continued.
“There was pressure on staff, both due to current staff vacancies and changes in a person's needs.” from the report
Recruitment records
minorTwo staff files did not initially include a full employment history and the date full-time education had ended. The information was provided after the inspection and checks were made on other files.
“The two files reviewed did not contain the date the employee had completed full-time education and a full employment history.” from the report
- 01Have all the works required by the recent fire-safety report now been completed?
- 02How are staff vacancies affecting staffing levels, continuity and support for people who need stability?
- 03How do you make sure agency and bank staff understand each person's communication and behaviour support needs?
- 04What improvements have been completed as records move to the new electronic care planning system?
- 05What were the previous ratings for Effective, Caring and Responsive, and when will these areas next be fully inspected?
This was a focused inspection of Safe and Well-led, with infection control also checked; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 2 November 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.
What inspectors found, January 2020
Rated Requires Improvement; inspectors found kind, personalised care, but weaknesses in risk records, medicines checks and quality monitoring.
The inspection was unannounced and took place on 28 November and 02 December 2019. One inspector spoke with people, relatives, staff and professionals, observed care, and checked care, medicines, staff training and management records.
The home was rated Requires Improvement overall. Safe and Well-led were both rated Requires Improvement. Inspectors found that epilepsy risk plans did not contain all the information staff needed, medicines records and competency checks were not always up to date, and quality audits did not identify these problems.
Responsive was rated Good. People had personalised care plans, communication support and activities. The home had a clear management structure and staff felt supported, but the provider breached Regulation 17 because its governance systems did not ensure records were accurate, complete and kept up to date.
Personalised care
Care plans reflected people's likes, dislikes, communication needs and emotional support needs. Staff adapted their approach to support independence while recognising when more help was needed.
“People's care plans were person-centred and contained a good level of detail about their likes, dislikes and how they would like to be supported to meet their needs.” from the report
Communication support
The home used different communication tools, including pictures, objects, easy-read information, signing and visual timetables.
“People were supported to use meaningful forms of communication which included the use of picture exchange communication systems (PECS), objects of reference, easy read information and Makaton or signing” from the report
Consistent staffing
Relatives reported seeing regular staff who knew the people living in the home well. Staffing was arranged to meet people's individual needs.
“Staff were deployed effectively to meet people's needs.” from the report
Activities and community access
People were supported with activities inside the home and could access the community with staff support. Inspectors observed baking, sensory activities and arts and crafts.
“We observed people were encouraged to participate in activities within the home.” from the report
Epilepsy risk plans
seriousSome epilepsy plans did not explain all relevant risks or what staff should do when people were away from direct supervision or overnight. This increased the risk that staff would not have complete written guidance.
“Individual epilepsy management plans did not identify all relevant risks to people and steps staff should take to mitigate these.” from the report
Medicines records and checks
seriousOpening dates were not consistently recorded on topical creams or medicines. Some as-required medicine information was inaccurate or out of date, and not all staff had a medicines competency review within 12 months.
“We found staff did not always consistently use opening date labels for people's prescribed topical creams or medicines” from the report
Weak quality monitoring
seriousThe provider's audits did not identify several problems with care records, medicines information, activity records and best-interest decisions. This was a breach of Regulation 17.
“The provider's governance systems were not always effective and failed to consistently assess, monitor and drive improvement in service delivery” from the report
Incomplete activity records
needs fixingPeople had activity opportunities, but records did not always show these consistently. One person's records suggested they had not been supported in the community for more than three weeks.
“Some people's daily records demonstrate they took part in regular community activities, however another person's records indicated they had not been supported in the community for more than three weeks.” from the report
End of life planning
minorNo one was receiving end of life care at the time. Inspectors recommended reviewing best practice to develop more proactive planning with people and relatives.
“We recommend the provider reviews best practice guidance to further develop opportunities for proactive end of life care planning with people and their relatives.” from the report
- 01How have you updated each person's epilepsy management plan, particularly for overnight periods and times when they are not under direct staff supervision?
- 02How do you make sure topical creams and other medicines have opening dates recorded correctly?
- 03When was each staff member's medicines competency last checked, and how often is this now reviewed?
- 04What checks now make sure care records, activity records and best-interest decisions are accurate and complete?
- 05What action has been taken following the Regulation 17 breach, and what evidence can you show that the changes are working?
This was a responsive focused inspection of Safe, Responsive and Well-led only; Effective and Caring were not inspected and previous ratings for those questions were used in calculating the overall rating. This explanation was written from the published report of 29 January 2020 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 House
4 rated inspections over 6 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- March 2019Goodstayed GoodSafe: GoodResponsive: GoodWell-led: Good
- September 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2014
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Report published without a new overall rating.
- February 2011
Registered with the Care Quality Commission on 3 February 2011.
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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26 live-in carers within about an hour of Hampshire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,020 to £1,260 a week. 23 can care for a couple. 14 years' experience on average.
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“He stayed with her throughout the pandemic, refusing to visit his own family, who lived nearby, to reduce the risk of infection.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.