CQC report explained · a nursing home
What the CQC found at Durban House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some risks, including choking, falls, weight loss and the building's safety, were not always assessed, reviewed or managed properly. Some medicines were not recorded as given, and PRN medicine instructions lacked detail.
- Effective?
- Good
- This question was not inspected during this visit. Its rating carried over from the previous inspection.
- Caring?
- Good
- This question was not inspected during this visit. Its rating carried over from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this visit. Its rating carried over from the previous inspection.
- Well-led?
- Requires improvement
- Governance systems were not effective enough to identify and fix problems. Records were not always accurate or complete, and new breaches were found despite an earlier improvement plan.
What inspectors found, November 2022
Rated Requires Improvement; inspectors found kind care but ongoing safety, safeguarding, recruitment and management shortfalls.
This was an unannounced focused inspection on 28 September and 5 October 2022. Inspectors checked whether earlier legal requirements had been met, looking only at Safe and Well-led. They spoke with people, relatives, staff and professionals, observed care, and checked records and the home.
The home had improved person-centred care and staffing was generally sufficient. People were treated kindly, the home was clean, medicines were given in a patient manner, and staff worked with health and social care professionals.
However, risks were not always assessed or managed properly. Medicines records were not always complete, recruitment checks were missing, safeguarding systems were not robust, and quality checks had not driven enough improvement. The overall rating remained Requires Improvement, as did Safe and Well-led.
Clean environment
The home had good standards of cleanliness and hygiene. Staff had infection control training and used protective equipment safely.
“The housekeeping team ensured good standards of cleanliness and hygiene were maintained throughout.” from the report
Staffing improved
The home was no longer in breach of the staffing regulation. Planned staffing levels were usually met, although agency staff were used and some staff remained concerned about cover.
“Sufficient improvement had been made at this inspection and the provider was no longer in breach of regulation 18.” from the report
Working with professionals
The home worked with GPs, social workers, mental health professionals, speech and language therapists and tissue viability nurses.
“There was evidence that the registered manager, acting manager and the staff team worked with a range of health and social care professionals” from the report
Risks were not consistently managed
seriousSome risk assessments were incomplete or conflicting. A person at risk of choking was left without supervision in the dining room for short periods, and some falls and weight monitoring records were not properly followed up.
“The provider had not done all that was reasonably practicable to ensure that all of the risks to people, including those arising from the premises, had been assessed and planned for.” from the report
Recruitment checks were incomplete
seriousThe home could not show satisfactory references for three staff, some DBS checks were not updated, and employment history and induction records were missing.
“Systems to ensure only fit and proper persons were employed were not sufficiently robust.” from the report
Safeguarding systems were not robust
seriousThe provider had not shown that it had made required referrals about the conduct of former staff and a nurse. Referrals were made after the inspection.
“Systems to safeguard people from abuse were not sufficiently robust.” from the report
Management checks were not effective enough
seriousThe improvement plan had marked some actions complete even though inspectors found continuing problems. Records and reviews were incomplete, including checks of incidents and clinical governance.
“The governance arrangements were not being effective at driving improvements and preventing new or additional breaches.” from the report
Activities were not consistent for everyone
needs fixingActivities were mainly provided in communal areas. Inspectors were not assured that people staying in their rooms had enough meaningful activity, after there had been no activity coordinator for about six months.
“We were not assured from records, that people cared for in their rooms, or those that chose to stay in their rooms, had sufficient access to meaningful activity.” from the report
- 01What has been done to make sure choking, falls, weight loss and other risks are assessed, reviewed and acted on promptly?
- 02How do you now check that all staff have satisfactory references, current DBS checks, full employment histories and recorded inductions?
- 03What safeguarding referrals have been made, and how do you make sure future concerns are referred without delay?
- 04How are missed medicines, missing eMAR signatures and PRN medicines now checked and followed up?
- 05What activities are now available for people who stay in their rooms, and how do you record their access to meaningful activity?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings carried over from the previous inspection. This explanation was written from the published report of 17 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, December 2021
Rated Requires Improvement; inspectors found risks from staffing, care planning, dignity, medicines and weak oversight.
This was an unannounced focused inspection. Two inspectors visited on 29 June 2021, spoke with staff and 11 relatives, and checked care records, medicines, staffing, safeguarding, infection control and building records. They also reviewed information after the visit.
The home was not always safe. Staff were not always available when people needed help, risk plans were incomplete, some falls and possible injuries were not properly investigated, and infection control and medicines practice needed improvement. Inspectors also saw examples of people not being treated with dignity or given person-centred care.
The overall rating was Requires Improvement. Safe was rated Requires Improvement and had fallen from Good at the previous inspection. Well-led remained Requires Improvement. This inspection only assessed Safe and Well-led, so the other question ratings were carried forward from the earlier comprehensive inspection.
Safeguarding knowledge
Staff had received safeguarding training and could identify possible signs and symptoms of abuse.
“Staff had been trained in safeguarding and were able to identify the possible signs and symptoms of different types of abuse.” from the report
Some infection controls
Inspectors were assured that the home was following shielding and social distancing rules, admitting people safely and arranging testing.
“We were assured that the provider was meeting shielding and social distancing rules.” from the report
Secure medicines storage
Unneeded medicines were securely stored and records showed they were witnessed when sent for disposal. Controlled drugs were also appropriately stored and recorded.
“There was clear evidence of no longer required medicines being securely stored, recorded and witnessed as being put for disposal.” from the report
Relative involvement
Relatives said they had been involved in care plan reviews and could ask questions about their relative's care.
“It was very much a two-way process. I could ask questions.” from the report
Staff availability
seriousInspectors found people calling for help when no staff were available. This included requests for help to avoid falling and to use the toilet.
“The provider failed to ensure sufficient numbers of staff were appropriately deployed to keep people safe and meet their needs at all times.” from the report
Risk management
seriousSome care plans did not explain how to manage risks linked to diabetes, falls, serious medical conditions or skin damage. Post-fall checks were also not always recorded.
“We were not assured that risks to people had been assessed and plans implemented to reduce these.” from the report
Unexplained injuries
seriousRecords did not show that some bruising had been investigated or that steps had been identified to prevent similar incidents.
“We were not always confident that the cause of bruising was investigated to ensure people were safeguarded.” from the report
Dignity and activities
seriousInspectors saw people left in uncomfortable or unsafe positions and found that meaningful activities were not always provided. Relatives also reported problems with personal belongings and reduced activities.
“The provider failed to create a culture that was person-centred and empowering for people.” from the report
Infection control
needs fixingStaff could not confirm that catheter care followed good infection control practice. PPE was not always used correctly, and some areas and furniture were not clean.
“Staff failed to consistently use PPE in accordance with best practice guidance.” from the report
Medicines records and treatment
needs fixingTopical creams were not always applied as prescribed. Diabetes care plans did not include instructions for medicines used to raise blood sugar levels.
“Where people were prescribed topical creams to be applied by staff, we found these were not always being provided.” from the report
- 01How many staff are deployed in each area of the home at busy times, and how do you make sure people can get help promptly?
- 02What changes have you made to risk plans and records for falls, skin damage, diabetes and other serious health conditions?
- 03How are unexplained bruises and other injuries investigated, recorded and followed up with families?
- 04How do you check that creams, diabetes medicines and other treatments are given as prescribed?
- 05What action has been completed to improve dignity, activities, lost belongings and the effectiveness of management audits?
This was a focused inspection of Safe and Well-led only; the other ratings were carried forward from the previous comprehensive inspection. This explanation was written from the published report of 2 December 2021 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 Durban House
4 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- November 2022Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- January 2019Goodstayed GoodSafe: GoodWell-led: Requires improvement
- November 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2014
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 11 January 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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