CQC report explained · a nursing home
What the CQC found at Kilburn Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, January 2022
Rated Requires Improvement; inspectors found kind and effective care, but safety checks, cleaning and leadership still needed improvement.
This was an unannounced inspection visit on 30 November 2021. Two inspectors visited the home, observed care, checked records and spoke with staff. An Expert by Experience also spoke with six relatives.
The home was rated Good for Effective, Caring and Responsive. Inspectors found that people were treated with kindness and dignity, received appropriate food and healthcare, and were supported to make choices and keep in touch with relatives.
Safe and Well-led were rated Requires Improvement. Three people at risk of choking did not have suitable care plans, one person did not have a behaviour support plan, some cleaning was not completed properly, and a fire safety enforcement notice was in place.
The provider had improved since the previous inspection and was no longer in breach of the regulations previously identified. However, there was still no registered manager, and quality checks needed to become more thorough and consistent. CQC said it would monitor progress and return.
Kind and respectful care
Inspectors saw staff treating people with dignity and compassion. Relatives spoke positively about the staff's kindness and respect.
“We saw staff treating people with dignity and compassion.” from the report
Suitable food and drink
People were offered choices and received food and drinks matched to their nutritional needs. Staff monitored weights and hydration.
“People were provided with food which met their needs and were provided a choice of meals .” from the report
Improved staffing
Inspectors found staffing levels were sufficient and recruitment checks were being completed safely. This addressed a staffing breach found at the previous inspection.
“Staff we spoke with told us that the staffing levels were sufficient and we saw people were attended to without delay.” from the report
Family involvement
Relatives were kept informed and were able to contribute to care discussions. The home also supported visits and telephone or video contact.
“Overall, people's representatives were kept informed about their relative's care and able to contribute in discussions about this.” from the report
Fire safety notice
seriousA fire inspection had identified risks and the provider had three months to address them. An action plan was in place, but the notice was still current at the inspection.
“There was a current enforcement notice from the fire service in regard to fire safety.” from the report
Missing risk plans
seriousThree people at increased risk of choking did not have care plans to reduce that risk. One person with behaviour that challenged also had no behaviour support plan, although new plans were put in place after inspectors raised this.
“we identified three people who were at heightened risk of choking but had no care plan to mitigate the risks.” from the report
Cleaning and hygiene
needs fixingSome kitchen cleaning tasks were not completed or recorded. Inspectors also found incorrectly labelled food and dirty equipment, including two hoists.
“Overall, the home was clean and tidy, however we found some equipment, including two hoists were dirty.” from the report
Limited activities
minorSocial and stimulating activities were limited because care staff could only provide them when they had time. The provider was recruiting an activities co-ordinator.
“Staff provided some social activity support when they were able to, but this had been limited.” from the report
End of life plans
needs fixingArrangements and staff training were in place, but end of life care plans did not contain enough detail and needed review.
“There were arrangements in place to support people at the end of their life, however the end of life care plans were not detailed and required further work.” from the report
- 01What has been done to address the current fire safety enforcement notice, and has the fire service confirmed that the risks are resolved?
- 02How are choking risks now recorded in care plans, and how do you check that staff follow the guidance?
- 03What cleaning checks are now in place for the kitchen, food labelling and equipment such as hoists?
- 04Has an activities co-ordinator been recruited, and what regular activities are now available?
- 05Who is currently managing the home, and when will a registered manager be in post?
This was an unannounced comprehensive follow-up inspection covering all five key questions, after an earlier focused inspection of Safe and Well-led. This explanation was written from the published report of 25 January 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, April 2021
Inspected but not rated; inspectors found important safety, staffing and management problems, although medicines were managed safely and relatives described caring staff.
This was an unannounced focused inspection on 3 and 9 March 2021. It began by checking infection prevention and control during the COVID-19 pandemic, then widened to look at Safe and Well-led.
Inspectors found that risks were not always identified or managed. Care records were sometimes out of date, staffing levels were not always enough, infection control rules were not consistently followed, and accidents were not always properly reviewed.
The home had no registered manager. Its quality checks did not always lead to action. Medicines were stored and given safely, and relatives described staff as caring, compassionate and knowledgeable.
The service was inspected but not rated overall. Safe and Well-led were both rated Requires Improvement. The previous Good rating was under an earlier provider and was not used to calculate this inspection's overall result.
Medicines
Medicines were stored securely, kept at the correct temperatures and given as prescribed. Records showed that medicines had been administered.
“Medicines were safely managed. Medicines were stored securely and at the correct temperatures.” from the report
Caring staff
Relatives said staff were compassionate and caring, and knew people well, although low staffing made their work harder.
“Relatives told us that staff were very caring, compassionate and knew people well.” from the report
Safeguarding knowledge
Staff had safeguarding training and knew how to raise concerns. Safeguarding incidents were reported to the local authority and CQC.
“Staff had received regular safeguarding training and knew how to raise any safeguarding concerns.” from the report
Working with health professionals
The home sought outside clinical support when people's health needs changed, including dietitian support and assessments for people at risk of choking.
“The manager and provider engaged and worked in partnership with others.” from the report
Risks and care records
seriousSome health risks were not fully assessed or recorded. Care plans had not always been reviewed and did not always give staff accurate information.
“Risks associated with people who had specific health needs, such as diabetes or epilepsy, were not always considered or documented.” from the report
Infection control
seriousInspectors saw staff and visitors not consistently following COVID-19 precautions. Screening, testing, training, social distancing and enhanced cleaning were not robust.
“Government guidelines for reducing the risk of COVID-19 in care homes had not been followed.” from the report
Staffing levels
seriousThere were not always enough staff to complete checks and care tasks on time. The home could not assure inspectors that agency staff had received a proper induction or information about people's needs.
“There were not enough staff to ensure people received the care they needed.” from the report
Learning from incidents
seriousFalls and other incidents were not always thoroughly reviewed. The home could not show that enough action had been taken to reduce the risk of repeat incidents.
“Lessons were not learnt from incidents to reduce ongoing risk.” from the report
Management and oversight
needs fixingThere was no registered manager. Audits and the improvement plan did not consistently identify problems or set clear timescales for fixing them.
“Quality assurance systems had not always been effective in identifying areas for improvement and driving quality.” from the report
Communication with relatives
minorRelatives gave mixed feedback. Some said they were kept informed, while another said it was difficult to obtain information and calls were not always returned.
“Relatives had mixed reviews in relation to the care people received.” from the report
- 01What has changed to make sure there are enough staff when people need two staff members or regular checks?
- 02How do you make sure agency staff receive an induction and clear information about each person's care needs?
- 03How are care plans and risk assessments reviewed when people's health needs change?
- 04What action has been taken after falls and other incidents, and how do you check that the action has worked?
- 05How are COVID-19 screening, testing, PPE training, social distancing and enhanced cleaning monitored now?
This was a targeted inspection of infection prevention and control that became a focused inspection of Safe and Well-led; the other key questions were not assessed or rated. This explanation was written from the published report of 24 April 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Kilburn Care Centre
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- January 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Requires improvementWell-led: Requires improvement
- June 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2020
Registered with the Care Quality Commission on 21 September 2020.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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