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 inspection we rated this question requires improvement, this rated remains unchanged. We found that some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The provider failed to ensure that people who use the service were protected from abuse and improper treatment at all the times. This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 The provider had failed to ensure the proper and safe management of medicines . This was a breach of regulation 12(2)(g) 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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We were not assured that leaders had the appropriate knowledge or experience to safeguard people using the service. Leaders did not always take appropriate action without delay when abuse was suspected and reported. The leaders did not always investigate the allegations thoroughly and timely and refer concerns appropriately. We identified failures in working with partners in a collaborative way to keep people safe, because the provider did not always inform the Local Authority and the CQC of all safeguarding incidents at the home. Although we acknowledge that all staff received safeguarding training and the care staff understood how to keep people safe and how to report concerns.

People and their relatives told us they felt safe at the service. People's comments included, "I feel my loved one is safe and well looked after, the staff are very good and look after them well", "The staff are very good and supportive", "I feel my relative is safe".

Whilst there was a safeguarding policy in place, leaders did not apply it to report or prevent abuse of people using the service. Managers did not show that they understood the local safeguarding policy and procedures, and the actions they need to take in response to suspicions and allegations of abuse. We identified an incident where the managers did not act appropriately when the care staff reported allegations of abuse. As a result, people were placed at risk of harm.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe environments during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service did not have safe effective systems for the appropriate and safe handling of medicines. We found several concerns about medication management. For example, care plans and risk assessments for medicines were incomplete for some people. They lacked person-centred information to ensure staff understood how to care for individuals' specific medicine care needs. Covert medicines (when medicines are administered in a disguised format) were not administered in line with the provider's policy and the best practise guidance. Care plans for 'when required medicines' (PRN) did not contain sufficient information for staff, such as dose instruction, alternative support, expected outcome, and when to refer if needed. Stock levels of certain schedule 3 and 4 controlled medicines were not managed by a robust process and no physical counts were performed on these medicines identified. This placed people at increased risk of not receiving their medication safely.

Staff were trained in medicines administration and had competency assessments completed annually. Staff said they were given induction, and training to use the computer systems.