Kilburn Care 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 Requires Improvement. There had been breaches of regulation relating to failing to effectively assess the risks to the health and safety of people using the service and failing to take reasonable steps to mitigate those risks. The provider had also not ensured staff notified the CQC, without delay, about incidents of abuse, or allegations of abuse, in relation to people using the service. 

Improvements were found at this assessment, and the rating has improved to Good. The provider was no longer in breach of regulations. This meant people were safe and protected from avoidable harm.

This service scored 75 (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 had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

At the previous inspection we found the provider failed to ensure their staff notified the CQC, without delay, about incidents, or allegations, of abuse in relation to people using the service. This was a breach of regulation. The failure to notify CQC about such incidents impeded our ability to monitor the quality of the service people received and placed people at a potentially increased risk of harm. At this inspection we found the provider had made significant improvements to their arrangements for monitoring incidents and making the required notifications to CQC. The provider was no longer in breach of regulations.

People were encouraged and supported to raise safety concerns with the provider. The manager and staff understood the importance of reporting safety concerns and learning lessons when things went wrong.

Systems were in place to support staff to report and record safety concerns and events when they arose. The manager investigated safety concerns and events and used the learning from these to support staff to continually improve their practice, reduce risk and keep people safe.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had an appropriate process for new referrals, obtaining a copy of the person’s initial care needs assessment, and then carrying out their own assessment, before deciding whether they would be able to provide support. There was an electronic care record system in place, which care staff had access to. This helped ensure people’s care was provided in a planned, responsive and organised way.

People were listened to by the provider’s staff when their initial care plans were being created. This helped ensure people were supported to receive continuity of care when they started receiving care from this service.

The provider had standard policies and procedures in place which reflected best practice in terms of safety and effective ways of working.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt comfortable when staff interacted with them. For example, a person’s relative told us, “My relative feels safe and comfortable and happy at the care home. I do not have any concerns regarding their safety.” Another person’s relative told us, “I feel a lot happier with my relative’s safety. Before I was seriously concerned. So the improvement is credit due to them.”

Staff used respectful language when describing people and their care needs. The provider had a comprehensive safeguarding policy and procedure in place, which included consideration of sexual safety and online safety. Staff received regular safeguarding training.People also had access to people outside of the service with whom they could raise concerns about their safety if necessary. For example, visiting health care professionals, and family members.

The provider carried out investigations into any incidents which occurred while providing a service to people. They also co-operated with safeguarding enquiries carried out by the Local Authority. The provider’s investigation findings were used by the manager to identify any lessons learned and actions to be taken to ensure people were protected from abuse.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider reviewed any incidents for recurrent trends or triggers. Information was shared with the staff so support arrangements could be changed to reduce recurrences. People, and their family members where appropriate, were involved in deciding how their individual risks would be managed and mitigated.

People’s individual risks were regularly assessed. For example, a person told us, “Managers ask me how I am getting on, and if I need things done differently.”

People’s care plans detailed how to support them with their complex care and health needs. The provider’s staff did not use restraint techniques when people became distressed or upset. Instead, staff used distraction techniques to positively support people and keep them safe.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider had made significant improvements in this area since our previous inspection. People were cared for in a safe environment which had been purpose built for use as a care home. Facilities and equipment were well-maintained and supported staff to deliver safe and effective care.

People lived in an environment which contained several areas which had recently been refurbished. A person’s relative told us, “There has been some decorating done, and some new furniture which looks better.” These changes had improved the atmosphere in the care home, and the provider now had an ongoing refurbishment plan in place.

The provider’s arrangements to monitor the safety and upkeep of the premises had improved. For example, a person’s relative told us, “I recently raised a concern with the manager about a set of drawers in my relative’s room that appeared to be broken. Within half an hour a new set of drawers was delivered to their room.”

The manager made sure there were enough qualified, skilled and experienced care staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The provider had decreased the numbers of agency care staff used since our previous inspection, by recruiting permanent staff. A staff member told us, “Recently we have recruited a fair number of new staff which is brilliant as we are no longer running off agency. However, the staff experience is obviously decreased a bit now, but in time, with the correct training and support, these staff will be a valued part of our team, I am sure.”

The manager had an effective programme of appropriate staff training in place, and staff told us they received the training they needed to support people safely. Staff received training to ensure they could meet people’s needs. This included training related to health conditions.

The manager encouraged staff to develop their skills and knowledge. For example, a staff member told us, “Another positive development has been the focus on career progression. Staff are being encouraged to develop their skills, take on new responsibilities, and work towards promotions. Several team members have already progressed into more senior roles, which has boosted morale and created a sense of growth and opportunity within the home. It’s been encouraging to see people recognised for their hard work and supported to advance in their careers.”

The provider had robust and safe recruitment practices in place to make sure all staff, including agency staff, were suitably experienced, competent and able to carry out their role.

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

The provider had an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. The provider had an infection prevention and control (IPC) policy and procedure in place, which staff had access to.

The provider’s IPC policy and procedures set out the clear roles and responsibilities around infection prevention and control. The provider ensured their staff had access to the necessary personal protective equipment (PPE) to support effective hygiene and infection prevention.

People lived in an environment which was generally clean and hygienic, and which was free from unpleasant odours.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People were involved in decisions about their medicines where appropriate, and their medicines were safely prescribed, supplied, stored, and administered in line with the relevant legislation.

People’s prescribed medicines were regularly reviewed by external medical professionals as part of their ongoing health care support.

The provider had appropriate arrangements in place for the safe management, use and oversight of controlled drugs. People had up-to-date information about their medicines available in their care plans and the provider’s medicine records.