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. At our last inspection we rated this key question requires improvement. At this assessment the rating is unchanged overall with four evidence categories for this assessment. This meant the service management and leadership was inconsistent and not always effective. Systems to assess, monitor and mitigate risks to the health, safety and welfare of people using the service were not fully effective. This placed people at risk of harm. This was a breach of regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Provider's process were not always effective in supporting the leaders to acquire the knowledge, experience and credibility to lead effectively. For example, the gaps in the leaders safeguarding knowledge were not identified prior to our inspection. This prevented the provider from having a transparent relationship with all relevant and stakeholders and driving improvements and protecting people who use the service.

The leaders at the home did not evidence the skills and competency to lead effectively at all the times. The leaders did not fully understand their responsibilities , for example to notify the Local Authority and CQC of relevant events. Staff told us that the leaders were visible and approachable.

The care staff told us they felt confident in speaking up and raising concerns. We saw examples of staff reporting and recording concerns appropriately. However, when the concerns were raised by staff, the service leaders did not always investigate, acted on and shared lessons promptly enough.

The provider had a safeguarding and whistleblowing policies and procedures in place to encourage staff to speak up, however the policies were not always followed by the service leaders. We found that not all safeguarding incidents were reported externally as per the provider's policy.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Based on the feedback from the service leaders we found that the management responsibilities and accountability were not clearly defined. For example, it was not clear who was accountable for completing statutory notifications about significant events. As a result, notifications were not consistently submitted to external organisations as required. This placed people at risk of not having the appropriate oversight of their care.

Provider's systems to capturing and managing organisational risks and issues were not fully effective. For example, provider's audits did not identify shortfalls in medication management identified during out assessment or the oversight in submitting notifications to external organisations. As a result some legal requirements were not understood and met by the provider.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff felt they were supported to develop their skills and knowledge. They felt encouraged to contribute improvement initiatives. Staff felt they can raise their ideas with the provider's for example during team meetings. However, staff did not always get updated promptly about outcomes when they raised concerns.

Provider's quality assurance arrangements were not always applied consistently. As a result improvements were not always identified promptly enough. Some of the provider's action to introduce improvements were reactive rather than proactive. We saw examples of missed opportunities to learn from incidents.