Kilburn Care 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. The provider failed to have systems and processes established which effectively assessed, monitored and improved the quality and safety of the services provided to people. They also failed to effectively assess, monitor and mitigate the risks relating to the health, safety and welfare of the people using the service.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating remained 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 43 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a shared vision, strategy and culture based on transparency, inclusion, and engagement. They did not understand the challenges being faced by their care staff.

The provider failed to ensure their staff understood the provider’s vision, values and strategic goals, or how their roles helped in achieving them. For example, a staff member told us, “You just don’t know where you stand at the moment. So many higher managers coming into the home and nobody knows why or who they are. There is no communication between anyone.”

The provider failed to ensure their vision, values and strategy had been developed through a structured planning process in collaboration with people who use the service, staff and external partners. For example, a staff member told us, “Through the years, and in recent months, we have had multiple different managers. Each with different ways of working. Each time we are made to feel like staff are the issue when we are only working as previously directed, you can understand this frustration. We would all love nothing more than to have a long-standing manager who works with us to deliver the best care.”

The provider failed to demonstrate a positive, compassionate, listening culture that promoted trust and understanding between them and their staff. For example, a staff member told us, “A lot of changes have happened over the last few months, a lot are stressful especially with the changeover of management quite frequently. A lot of regular staff have left; some on their own accord and some not, this is stressful as you don't know if your job is safe.”

The provider did not have leaders at all levels who understood the context in which they delivered care, treatment and support, or who embodied the culture and values of their organisation. Leaders did not have the skills, knowledge, experience and credibility to lead effectively.

The provider had not had a manager registered by CQC at the nursing home since 2021. In recent years there had been a succession of interim managers. However, the lack of consistent management at the service meant the provider failed to ensure people always received a good standard of care and that risks were always well managed.

After the previous assessment the provider had assured the CQC that they would put in place improvements to their processes to ensure their staff made the necessary notifications to the CQC. Those improvements had not been effective and had not been sustained.For example, during this assessment we found 10 examples, from the preceding 3-month period, of incidents which should have been notified to the CQC by the provider. This was raised with the provider by the inspector, and the provider told us they would retrospectively make the necessary notifications to the CQC and take action to improve their monitoring of incidents and notifications.

The provider’s senior leaders had been visible at the service, but they had not engaged effectively with their staff team. For example, a staff member told us, “Senior managers do not often attend the building unless we have inspections, or the Local Authority team are in. We have seen a lot more of them recently due to having social workers, or other external agencies, attending most days.”

People did not always feel they could speak up and that their voice would be heard. The provider did not encourage staff to raise concerns. For example, the provider was not able to produce evidence of staff feedback surveys having been carried out with their team over the previous 12 months. The provider recognised some of their staff had low morale but attempts to address this had not been effective.

Staff were not confident their voices would be heard by the provider. For example, a staff member told us, “I haven't said anything to the new manager, and in the past I haven't seen the point in saying anything because nothing seems to get any better. I'm hoping things are going to change.”

Staff understood how to raise their concerns about the service externally, to the Local Authority and to the CQC. When concerns were raised by external agencies, the provider investigated the issues, but there was little evidence of lessons being learned or acted on to prevent recurrence.

Some staff told us they felt insecure in their work and recognised the service needed to improve, but did not feel able to raise this with the provider. For example, a staff member told us, “I am not happy with the constant turnover of management, the fact that more permanent staff are leaving as a result of being over worked and undervalued; meaning we are about to run with more agency staff.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had policies and procedures for inclusion and diversity within the workforce. For example, recognising people’s protected characteristics and ensuring appropriate measures were in place to support these. Protected characteristics are a set of nine characteristics that are protected by law to prevent discrimination. For example, discrimination based on age, disability, race, religion or belief and sexuality.

The provider did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. The provider was in breach of the legal requirement to have established systems or processes in place which operated effectively to assess, monitor and improve the quality of the services provided to people. Their systems and processes also failed to effectively assess, monitor and mitigate the risks relating to the health, safety, and welfare of the people receiving a service.

The provider’s leaders were not always knowledgeable about the issues and priorities for the quality of care received by people living at this service. The provider had a range of quality audit tools which were not being used effectively to identify problems at the service. When the provider’s systems and processes did identify issues, they were not addressed in a timely manner.

The provider’s fire safety assessment and monitoring processes had not identified defects in the building’s structural fire prevention fixtures. This increased the potential of people, visitors and staff being harmed in the event of a fire.

The provider’s health and safety assessment and monitoring processes failed to identify some areas of the care home which were damaged or in poor condition. This increased the risk that service users may be harmed and decreased the quality of people’s experience of receiving care.

The provider’s health and safety assessment and monitoring processes failed to identify potential risks to people from wardrobes not being securely fastened to the walls in some bedrooms. They also failed to identify potential burns risks from uncovered hot water pipes in areas accessible to the service users. Additionally, the provider’s processes failed to identify potentially increased risks to people’s health and wellbeing posed by the poor management of water safety at the location. This increased the potential of people to come to harm.

The provider’s infection prevention and control assessment and monitoring processes failed to identify increased risks to people’s health and wellbeing posed by the poor hygienic condition of some areas of the location.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement. The provider understood the importance and benefits of working alongside other professionals. The provider confirmed they collaborated with external safeguarding teams in the investigation of accidents or incidents.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

The provider did not have a good understanding of how to make improvements happen. They had a continuous improvement plan in place which was not effective in tracking the progress and implementation of necessary service improvements. The provider did not always involve people using the service, their families, and staff, in identifying and evaluating areas for service improvement

The provider did not have effective systems in place to ensure that learning happens when things go wrong and staff were not consistently encouraged to contribute to improvement initiatives. Staff told us they did not always feel encouraged to speak up with ideas for improvement and innovation.