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-ledWell-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 as Requires Improvement. The provider was also in breach of regulation as they 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 this assessment the rating has improved to Good, and the provider is no longer in breach of regulations. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had made significant improvements in this area since our previous inspection. The manager had a vision for a person-centred care home service which they shared with staff.

Staff told us they understood how their role helped in achieving the vision. A staff member told us, “Finally we have an efficient, supportive, knowledgeable individual to run the care home. [Name] is a fabulous manager! I have worked here for many years, so I have seen my fair share of managers. Nothing compares.” Another staff member told us, “The managers are supportive and approachable, and the team as a whole is kind and respectful towards the people who live here. The culture in the home has definitely improved, and I feel that residents are treated with dignity and compassion.”

Staff and the manager demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service.

Staff at all levels received training to ensure they understood equality, diversity and human rights, and so they understood the need to prioritise safe, high-quality, and compassionate care.

The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The provider had made significant improvements in this area since our previous inspection. They had appointed a manager who had the experience, capability, and integrity to ensure the care home service met people’s needs and that risks were well managed. The manager and senior staff were visible and led by example, modelling inclusive behaviours.

The provider had effective recruitment processes in place to ensure new staff joining the care home were suitable and safe to appoint.

The manager was knowledgeable about issues and priorities essential to ensure the quality of services and was alert to any examples of poor culture that may affect the quality of people’s care and have a detrimental impact on staff. A staff member told us, “Based on the progress made recently, I would feel comfortable with one of my own family members living at Kilburn Care Home if they needed this level of support.”

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

The manager encouraged staff to raise concerns and promoted the value of doing so. When concerns were raised, the manager investigated sensitively and confidentially. Where lessons were learned, they were shared and acted on.

The manager told us that when something goes wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again.

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 had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

At our previous inspection we found 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 had made significant improvements in this area since our previous inspection and was no longer in breach of regulations.

The provider had clear and effective governance, management and accountability arrangements in place. Staff understood their role and responsibilities, and the manager was effective at directing the actions, behaviours and performance of staff.The provider had successfully embedded systems to manage the performance of the care home service, and risks to the quality of the service received by people.The manager ensured that necessary notifications to external agencies, such as the Local Authority safeguarding team and the Care Quality Commission were submitted in a timely manner.

The provider had organised and effective arrangements in place for the availability, integrity and confidentiality of data, records and data management systems. The provider used a combination of electronic and paper-based records. The provider used that information effectively to monitor and improve the quality of care people received.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The manager understood the importance and benefits of working alongside other professionals. They collaborated with external safeguarding teams in the investigation of serious accidents or incidents. Staff also worked in partnership with external health care professionals and community health services to ensure people received effective care.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The provider had made significant improvements in this area since our previous inspection. The provider and manager had a good understanding of how to make improvement happen. The provider had a continuous improvement plan in place, which was used appropriately to track improvements which had been identified by the manager and staff as being needed. The approach was consistent and included confirmation that required improvements had been made.

The provider had developed processes to ensure learning happened when things went wrong. For example, there had been quality of care issues caused by a reliance on agency care staff to cover staff sickness absence and annual leave. This had created additional pressure on the regular care staff and meant people were often being supported by staff they did not know.

The provider had taken action to increase the numbers of employed staff and had built a pool of directly employed relief staff. This meant shifts could more often be covered at short notice without always having to rely on agency staff, or the good will of existing staff. This improved the quality of care experienced by people living in the care home.