The Care Quality Commission (CQC) has downgraded the rating of Dover House in Dover, Kent from good to inadequate and placed it into special measures to protect people following an inspection in November and December.
Dover House, run by Dover House (GC) Limited is a residential care home providing accommodation with nursing and personal care for older people and people living with dementia. The home can support 86 people across four floors, and 72 people were living there at the time of the inspection.
CQC carried out the inspection following a serious incident involving someone using the service. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken.
Inspectors found the home breached seven legal regulations relating to person-centred care, consent, safe care and treatment, safeguarding, premises and equipment, staffing and good management.
Following the inspection CQC have served four warning notices to the service to focus the attention of leaders on providing safe care and treatment, safeguarding, premises and staffing
CQC has downgraded the ratings for how safe, effective, caring, responsive and well-led the service is from good to inadequate.
CQC has also placed Dover House into special measures which involves close monitoring to ensure people are safe while they make improvements. Special measures also provides a structured timeframe so services understand when they need to make improvements by, and what action CQC will take if this doesn’t happen.
Catriona Eglinton, CQC deputy director of operations in Kent, said:
“When we inspected Dover House, we found that leaders didn’t have a grip on serious and widespread problems at the home. Systems to monitor quality and safety weren’t working, and even when audits identified issues, no action was taken to address them.
“As a result, people were living in unacceptable conditions. On two floors there was an overpowering smell of urine, with dirty carpets and sticky floors. We saw residents wearing urine-soaked clothing who hadn’t been supported to use the bathroom. Relatives told us they’d raised concerns about the smell and cleanliness for months, yet nothing had changed.
“There were incidents of people displaying anxious, distressed and aggressive behaviour, resulting in harm to others living at the service. People had unexplained bruising that wasn’t always recorded or investigated. Falls, both witnessed and unwitnessed, weren’t consistently documented and staff lacked the training and care plans needed to support them safely. Leaders hadn’t identified these failures, meaning opportunities to learn lessons and prevent further harm were missed.
“We also found a person with a catheter who had passed very little urine over a 24-hour period, which had gone unnoticed. Records showed they weren’t receiving enough fluids to remain healthy. The risk of infection, and safeguarding concerns weren’t always raised when they should have been.
“No one should have to live like this in a place they are supposed to call home. After our visit, we made it clear to leaders at Dover House that urgent and significant improvements were needed. Immediate steps were taken, including bringing in additional staff to support people, alongside an action plan to drive the required improvements.”
Inspectors found:
- Staff did not consistently report concerns to external bodies (e.g. local authority, CQC), and some did not know who to contact, risking serious issues being missed.
- Leaders hadn’t ensured there was sufficient overnight staffing and overstretched daytime staff led to task-focused care rather than person-centred support.
- Leaders failed to work effectively with people and healthcare partners to understand and deliver what safety meant to them.
- The service didn’t make sure bedrooms had personal and homely features; one room was poorly maintained, with unclean furniture, missing fittings, malodour, and clothes affected by the smell.
However, inspectors also found:
- Staff said they were well supported by the registered manager, who had been in post for four months and acknowledged improvements were needed.