Dovehaven Grove

The service was in breach of legal regulation in relation to infection prevention and control, management of medicines, safe environments, risks and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Work was ongoing to ensure regular and up to date supervisions were taking place with the staff team. There were gaps in the staff training, and not all training had been undertaken when refreshers were due. Concerns were identified in relation to the environment and infection prevention and control.

Some records we reviewed included conflicting information about how to manage people’s risks. Care plans included information about people but again these were sometimes conflicting. Staff told us they included people and relatives in the assessment and reviews of their individual care needs.

The service had in place a range of quality monitoring tools from both the management and senior management. However, improvements were still needed as systems and processes were not always effective in identifying the concerns we found during this assessment, nor did they confirm the actions taken to address the findings during our site visits. There was some feedback about the difficulties the service had in engagement with professionals to ensure timely assessments of people were undertaken.

Systems were in place to monitor incidents and accidents and lessons learned, staff knew how to manage incidents and accidents. Safeguarding information was recorded including detailed route cause analysis. People were supported to access relevant professionals as they needed, and partners discussed the relationships between them and the service. We observed professionals visiting during our assessment. Professionals told us about the actions the service had taken to monitor assess and support improvements for people.

Information and guidance to support the delivery of evidence-based care and treatments was available including oral care guidance. People were provided with meals and fluids according to their needs and we saw a mainly positive meal time experience, but this was not the case for all. Information and guidance was available to support people’s needs in line with evidence-based practice.

Information in relation MCA (Mental Capacity Act) and DoLS (Deprivation of Liberty Safeguards) was recorded in most care records but not all where they were required and 1 required review to ensure it reflected the persons individual need in relation to appropriate meal support. Staff understanding of MCA, DoLS and bests interests was limited.

People were provided with good care, and the individual needs were supported. The registered manager discussed the work that was required to make improvements in the quality of the care records. Staff understood people’s needs and how to support them. Activities were seen to be taking place on both days of the assessment visit and people were seen to be enjoying these, staff talked about how they supported people’s individual communication needs and ensured people’s choice and rights were considered. Most staff were positive about the support from the management team and were confident that the registered manager had settled into their role.

Care records had been reviewed and checks on preadmission assessments had been completed, daily records and handovers were being recorded and included information about the involvement of professionals, we saw professionals visiting during our assessment. Staff discussed the way they supported communication needs for people; the management team talked about the specific needs for 1 person and how they helped them to communicate effectively. Consideration about people’s end of life care and choices were noted.

Staff knew what to do in relation to handling complaints, records were seen in relation to correspondence for complaints received. People and staff were asked for their views, and you said, we did information was on display in the entrance to the service. A range of activities were being provided, and we saw people were enjoying these.

Policies information and guidance were available for the staff team to support them and guide them in providing care and supporting people.

The registered manager talked about the improvements required in the service and were committed to making the necessary improvements. Staff meetings were taking place and minutes confirmed the staff involvement in these. A range of policy and guidance was available to support the staff team in their roles.

Feedback was being sought in the form of surveys, and you said we did feedback. People and staff were positive about the registered manager and senior team, and most said they felt valued and that the management were open and visible in the service. There was evidence of the involvement of people in the community and accessing activities. The provider used innovative technology to support the reduction of falls and monitor people’s pain.