Kingston Rehabilitation Centre

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Management arrangements in place did not ensure good quality support consistently. At the time of this assessment the service did not have a CQC registered manager, but the provider was actively looking to recruit a manager with the experience and skills necessary for the home. There was continuous support provided for the home by the regional manager who knew the service and people well. However, areas for improvement identified during this assessment suggested there was a lack of management to oversee the quality of care being provided at the home and to drive improvement, making sure people were not at risk of avoidable harm.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider did not have clear roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

There were governance systems in place to monitor the care being provided for people. Audits undertaken were in relation to infection control, medicines and people's care records. However, these systems were not operated effectively because of a number of concerns we found during this assessment that had not been identified through the provider’s quality systems. This was in relation to the medicines and risk management, staff support, people’s rights to consent, activities, assisted communication and dining experience.We found that audits were not always regularly completed and/or actioned which meant the provider did not have a comprehensive and up to date overview of the services being provided for people. This included a call bell audit not being undertaken for August 2025 which resulted in a delay in identifying staff response times being greater than the target being set by the provider. We also found poor practice not being picked up in good time because the wound care audit was not completed for September 2025.

This meant that governance systems in place were not operated effectively to ensure safe care provision. The provider was in breach of the legal regulation in relation to good governance.

The provider understood their duty to collaborate and work in partnership. They shared information and learning with partners and collaborated for improvement.

People felt confident to raise their concerns should they have any, commenting “If I’m not happy I will say something.” Most family members told us they were provided with opportunities to discuss issues and problems. Healthcare professionals said there was a good response to feedback from the service, commenting, “Theytake feedback constructively and will try to improve when possible.”

The provider did not always focus on continuous learning, innovation and improvement. They did not always actively contribute to safe and effective practice.

We saw a ‘Service Improvement Plan’ being used to monitor actions necessary for improvement. Issues arising in different sectors of the home were put into actions, dated and allocated for completion. However, during this assessment we identified that people were continuously put at risk of harm because of the same nature of issues and concerns arising. This meant that either the set actions to improve were not always robust and/or that the actions were not carried out effectively.