Kilburn Care Centre

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.

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 32 people using the service. The service accommodates people in one building over two floors. The home is divided in to 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

Risks associated with people's care had not always been identified, mitigated and monitored. Staff were not always following COVID-19 government guidelines and good infection control practices. Sufficient staffing had not always been deployed to ensure people’s needs were met in timely manner. Systems and processes which had been implemented to monitor potential safeguarding concerns in the service had not been used effectively.

The home currently had no registered manager; however, a regional support manager was in post to support the running of the service. The provider had oversight of the service and carried out regular visits to monitor the quality of people's care, however actions had not always been taken to make improvements. Accidents and incidents were not always reviewed and thoroughly analysed to reduce the possibility of similar incidents reoccurring.

Relatives told us that staff were very caring, compassionate and knew people well.

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

Rating at last inspection

The last rating for this service was Good (published 16 June 218) This was under the previous provider. Ratings from previous comprehensive inspections for those key questions have not been used to calculate the overall rating at this inspection as these were awarded to a previous provider. The overall rating for the inspection will be inspected not rated.

Why we inspected

We undertook targeted inspection and 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 coronavirus and other infection outbreaks effectively.

We inspected and found there was a concern with infection prevention and control procedures and oversight at the service, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

We have found evidence that the provider needs to make improvement. Please see the Safe and Well-led sections of this report.

You can see what action we have asked the provider to take at the end of this full report.

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.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service. We have identified breaches in relation to safety, staffing and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.