Durbia Healthcare Ltd improved from Inadequate to Good overall following a focused follow-up inspection, with Safe rated Good after resolving breaches in medicine management, risk assessment, and recruitment. Well-Led remains Requires Improvement as the newly introduced governance systems and external partnership-building need more time to demonstrate sustained effectiveness.
Concerns (4)
moderateGovernance: “more time was required to ensure these new processes and audits identified risks and incidents were actioned appropriately.”
minorLeadership: “the registered manager was working to develop open and trusting relationships with other professional such as the local authority and healthcare professional and more time was needed”
minor
Person-centred care
: “More time was needed to fully reflect and evaluate on whether people's experience and care provided supported them to meet their goals.”
minorCommunication with families: “more time was required to allow the provider to demonstrate they were able to act on people's feedback and maintain standards going forward.”
Strengths
· Significant improvements to medicine management and administration since last inspection; MAR charts completed in line with best practice guidance.
· Staff recruited safely with robust recruitment checklists and appropriate DBS and reference checks in place.
· Staff received upskilled training in oxygen therapy, catheter care, safeguarding, and medicine administration with competency checks evidenced.
· Care plans reviewed and updated to provide clear, person-centred guidance including emergency situations such as choking.
· Registered manager communicated openly with people and relatives about previous failings and involved them in lessons-learned action planning.
Durbia Healthcare Ltd was rated Inadequate following a focused October 2023 inspection, with enforcement conditions imposed for breaches of Regulations 12, 17, and 19 covering unsafe medicines management, absent or inadequate risk assessments and care plans, and failure to ensure fit and proper staff recruitment. The service entered special measures, having failed to improve from a prior Requires Improvement rating, with widespread governance failures and ongoing risks to the 14 people supported.
Concerns (10)
criticalMedication management: “Staff administered medicines to people they had not prepared or dispensed. Staff signed records to show medicines had been administered at times they were not present at people homes.”
criticalCare planning: “Where people needed supported with oxygen therapy and equipment such as a ventilator, there was no guidance for staff on how to support with this equipment.”
criticalStaff training: “Only 45% of staff had received training in epilepsy and 54% in pressure area care. This placed people at ongoing risk of harm.”
criticalStaff competency: “Competency checks for staff on administering medicines had been completed by a staff member who had not received additional training to complete this task.”
criticalGovernance: “The provider failed to put reliable and effective monitoring systems in place to ensure there was good oversight of the service in relation to care planning, risk management.”
criticalSafeguarding: “Lack of training for staff, and the absence of comprehensive risk assessments and person centred care plans placed people at risk of avoidable harm.”
criticalRecord keeping: “Gaps were identified in MAR charts. Staff had not recorded why these medicines had been administered and audits had failed to identify these gaps.”
criticalLeadership: “The provider did not understand the principles of good quality care and had not developed systems and processes to ensure compliance with regulations.”
moderateIncident learning: “We found no action had been taken to embed a culture of learning lessons from previous incidents.”
moderatePerson-centred care: “The culture was not consistently person centred and the provider did not record outcomes for people.”
Strengths
· Staff described by some people as 'kind and compassionate' and 'willing to go the extra mile'
· MCA policy in place and staff knowledgeable about Mental Capacity Act principles
· Clear and up-to-date infection prevention and control policy with PPE provision for staff
· Complaints policy in place; one relative reported concerns were acted on quickly by the manager
· Regular team meetings and staff supervisions were held
Quality-Statement breakdown (10)
safe: Staffing and recruitment; Learning lessons when things go wrongInadequate
safe: Using medicines safelyInadequate
safe: Assessing risk, safety monitoring and managementInadequate
safe: Systems and processes to safeguard people from the risk of abuseInadequate
safe: Preventing and controlling infectionGood
well-led: Managers and staff being clear about their roles, quality performance, risks and regulatory requirementsInadequate
well-led: Working in partnership with othersRequires improvement
well-led: Promoting a positive culture that is person-centred, open, inclusive and empowering