Kilburn Care Centre

Updated 25 January 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors completed a site visit and an Expert by Experience made telephone calls to relatives to seek their feedback. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Kilburn Care Centre is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service did not have a manager registered with the Care Quality Commission. There was an interim manager in place at the time of our inspection. This means that the provider is legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed our information we held about the service. This included information received from local health and social care organisations, a relative and statutory notifications. A statutory notification is information about important events, which the provider is required to send us by law, such as allegations of abuse and serious injuries. We reviewed the last inspection report. The provider had not been required to complete a Provider Information Return. This is information providers are required to send us with key information about the service, what it does well and improvements they plan to make. We gave the provider the opportunity to share information with us.

During the inspection

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We spoke with the interim manager, regional director, agency nurse, cook, domestic staff and four care staff. We reviewed a range of records, included in part, seven people's care records. We looked at two staff files and two agency staff profiles in relation to recruitment, and a variety of records relating to the management of the service, including incident records and analysis.

After the inspection

We continued to seek clarification from the provider to validate evidence found. This included but was not limited to the provider's current action plan, training data, policies and procedures and meeting records. The Expert by Experience spoke with six relatives for their feedback about the service.

Updated 25 January 2022

About the service

Kilburn Care Centre is a care home providing personal and nursing care. Kilburn Care Centre is registered to accommodate 49 people. At the time of the inspection there were 20 people using the service. The service accommodates people in one building over two floors. The home is divided into two areas; the main nursing unit and a 10 bedded residential unit. The residential unit was not used due to refurbishment work. Both areas had separate adapted facilities with lounge and dining areas on each unit. A garden and enclosed patio were also available that people could access.

People’s experience of using this service and what we found

Processes were in place to ensure risks to people's health and safety were assessed and, on most occasions, actions were taken to mitigate the risks. Where we found areas for improvement in regard to mitigating risks, the provider responded to our feedback promptly.

The provider was in the process of mitigating environmental risks and there was an action plan in place on how to address these.

The provider's quality monitoring systems had improved since the last inspection, however these required further work to provide assurance.

Some areas of infection, prevention and control required improvement and we signposted the service for further support on this.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. Processes under the Mental Capacity Act and Deprivation of Liberty Safeguards had been followed to ensure people who may be deprived of their liberty were protected.

Staffing levels were sufficient, and staff were recruited safely. The provider had ongoing recruitment.

Staff had adequate training and support from the management team.

Opportunities for social and stimulating activities had been limited to when care staff were able to support these, but the provider was in the process of recruiting an activities co-ordinator.

People's representatives considered their relatives to be safe and well cared for. They spoke highly of the staff saying they treated their relative with kindness, respect and dignity.

People were supported to take their medicines and medicines were managed safely. People were supported to eat and drink safely and to have a choice in what they ate and drank.

We saw evidence of supporting people to maintain their independence and to make daily choices about their care.

Overall, people's representatives were kept informed about their relative's care and able to contribute in discussions about this.

There were processes in place for the management of concerns and complaints.

Managers were in contact with people and their relatives and this provided opportunities for

feedback about the service to be given.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

This service was registered with us on 21 September 2020 and this was the first comprehensive inspection. We undertook a focused inspection which included the key questions of safe and well-led (published 24 April 2021). We rated the questions requires improvement and there were breaches of Regulation 12 Safe care and treatment, Regulation 17 Good governance and Regulation 18 Staffing.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Kilburn Care Centre on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.