Kingston Rehabilitation Centre

We assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities that most people take for granted.

This assessment was carried out due to the receipt of concerns about the service. We reviewed 16 quality statements across all 5 key questions, ‘Is the service safe, effective, caring and responsive and well led?

People were at risk of harm because the quality systems were ineffective meaning that although actions had been taken to address care and safety matters they were not always effective.

The service was responsive to arising matters and the culture was proactive in seeking solutions. However, there was not always follow through and we identified that the same issues arose despite action being taken to address. For example, safeguarding investigations highlighted continuing care provision matters that persisted despite there being a service improvement plan. The lack of a registered manager contributed to this. Overall, the management team was approachable and open to feedback but was not fully utilising learning to maximise improvements.

We identified that staff did not always provide care to meet people’s needs that was safe and we found that staff were not always having regular supervision. Some staff were also working long shifts over many days.

Medicines systems needed improvement. Despite there being a quality system to audit medicines we identified a number of failings during our site visit. Our structured observations carried out during the site visit also highlighted areas where staff needed to be more person centred in their care provision to people. Although the majority of staff were observed to be caring and kind and people using the service gave us positive feedback.

The provider was in breach of the legal regulations relating to safe care and treatment, staffing and good governance.People and those important to them were confident to give feedback about the care delivery. People were involved in assessments of their needs. Systems and processes were in place for recording, reporting and investigating the safeguarding activity. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.