Kingston Rehabilitation Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Lessons were not always learnt to continually identify and embed good practice.

Systems were in place to monitor incidents and accidents taking place. Monthly incident and accident analysis was undertaken by the service to identify trends and actions necessary so that practice could be improved where a shortfall was identified. Lessons learnt from the incidents were shared with the staff team and included how the service supported people with diabetes to manage their blood sugar levels.

However, we identified that the wider learning systems needed development in order to be fully effective. For example, despite there being a service improvement plan we found care failings during our site visit as well as failings for areas that the provider had identified for improvement.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. Measures taken to safeguard people were not always effective because of a number of safeguarding concerns being raised at the service.

The provider shared concerns as necessary. Systems were in place for reporting, recording and investigating any safeguarding concerns received. Staff knew how to protect people from abuse. Their comments included, “I can go to the manager to report if needed. They address a safeguarding concern” and “[The staff team] report [concerns] to their line manager or above if not dealt with. We can escalate to the safeguarding team if needed and not dealt with.”

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Our review of safeguarding investigations carried out in 2025 identified that, in some cases, it was concluded that people were at risk of neglect due to lack of timely interventions, poor documentation and inconsistent checks in relation to catheter care and pressure sores. This included a person undergoing a surgical procedure possibly because of the poor skin integrity checks and lack of timely intervention from the staff team.

Actions had been taken by the provider to mitigate the identified risk, including introducing a wound management pathway to improve consistency in wound care delivery. However, during our site visit we identified recording gaps related to turning and positioning. We found daytime records not being completed by staff for 2 days for a person being assessed at high risk for pressure sores.

Shortfalls in meeting people’s individual care needs safely were also highlighted by some of the external healthcare professionals that we spoke to, noting people’s conditions had not always been escalated, addressed and monitored appropriately. A healthcare professional told us, “Staff make a genuine effort to understand and respond to individual care needs, but their effectiveness is sometimes limited by inexperience and a lack of structured support.”

This meant that people were continuously put at risk of harm. The provider was in breach of the legal regulation relating to safe care and treatment.

The service had an inhouse therapy team to provide people with occupational therapy and physio support when needed.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

The provider did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Quality of care was affected because of the agency staff used daily to cover shifts at the service. A person told us they did not “always” feel safe because of the continuous changes in staff. A family member said, “Recently [the service] have got too many agency [staff]. It is a concern as [name of the resident] struggles with new people, he gets distressed and refuses personal care if they are new.” Concerns were also raised regarding the staffing levels. Family members’ comments included, “Staffing levels are not enough at peak times, like getting up and going to bed. [My relative] asks to go to bed but it can be 1 hour 40 minutes wait for staff to be available” and “Hoist can be a wait of 30, 40, 60 minutes, due to shortage of staff, [my relative] is waiting to go back to bed as tired and they say that they are waiting for staff to come back from lunch.” A healthcare professional said that “the level of staffing doesn't allow [the staff team] to work at ease due the level of patients' level of dependency.” Rotas reviewed showed that some permanent staff were working 12-hour shifts and consecutive days, on one occasion 10 days in a row.

Systems and processes in place did not ensure continuous support for the staff team. Appraisal records viewed were lacking information in relation to the support being provided for staff to develop in their role. Staff supervisions were not regular and for some staff members the supervision records could not be found for this year.

Most healthcare professionals we spoke with, told us they had concerns regarding staff knowledge and skills. Their comments included, “Some staff have limited knowledge on management of patients, which can be evident especially on managing diabetes. Some are not appearing confident in managing certain clinical needs.” Records also showed some gaps in staff training. Training for ‘Catheter care’ was not completed by all care staff, including nurses. Hence, at the time of this assessment, another safeguarding concern was reported relating to the catheter management at the service.

This meant that people were placed at risk of harm. The provider was in breach of the legal regulation relating to staffing. Staff were required to undertake pre-employment checks before they started working with people.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies as necessary.

People and their relatives told us that staff used personal protective equipment (PPE) effectively and safely, commenting, “Room kept clean and cleaned every day. Staff use PPE and always have name tags on” and “Always PPE, gloves and aprons.”

The provider did not always make sure that medicines and treatments were safe and met people’s care needs and capacities.

Records showed that in 2025 there were a number of medicines errors reported in relation to records, stock management and administration of the medicines at the service. Some of the incidents resulted in people not receiving their medicines safely and as prescribed. During our site visit we identified errors and inaccuracies related to the recording of people’s medicines which had not been identified via the provider’s quality assurance processes.

Furthermore, the most recent provider’s monthly medication audit highlighted unsafe practices in relation to storage, recording, stock management and administration of people's medicines. This included recording gaps in relation to controlled drugs checks and inconsistent data regarding the risks when people consumed their medicines. We also saw the actions from the previous medicines audit not being fully completed.

This meant that people were put at risk of harm because the provider had not taken appropriate actions in a timely manner to mitigate the identified risks. The provider was in breach of the legal regulation relating to safe care and treatment.