South London Rehabilitation Centre Ordered to Make Improvements Following Critical CQC Inspection
A rehabilitation centre in South London has been instructed to enhance its operations after a care watchdog identified significant shortcomings in staffing practices and patient safety protocols. The Care Quality Commission (CQC) conducted an inspection at Kingston Rehabilitation Centre, operated by CHD Living, which revealed that individuals were placed at risk due to failures in several key areas.
Critical Findings on Staffing and Safety Procedures
The inspection, carried out in September last year following safeguarding concerns, found the provider in breach of legal regulations concerning safe care and treatment, staffing levels, and effective governance. Inspectors reported that people were "continuously put at risk of harm" because the service did not adequately collaborate with patients to manage risks, and staff failed to deliver care that was consistently safe and supportive.
One of the most alarming discoveries involved staffing rotas, which showed that some permanent employees were working 12-hour shifts on consecutive days, with one instance of a staff member working such shifts for ten days straight. This practice raised serious concerns about staff wellbeing and its potential impact on care quality.
Specific Concerns About Patient Care and Management
The CQC's review identified multiple areas where patient safety was compromised:
- Poor record-keeping and inconsistent checks for catheters and pressure sores
- Gaps in documentation for turning and positioning patients at risk of pressure sores
- Medication errors involving records, stock management, and administration
- Ineffective safety monitoring and safeguarding measures
Healthcare professionals informed inspectors that patient conditions were not always escalated, addressed, or monitored appropriately. One individual commented that while staff made genuine efforts to understand care needs, "their effectiveness is sometimes limited by inexperience and a lack of structured support."
Impact on Patients and Families
Family members reported significant delays in care due to staffing shortages. One relative noted that during peak times, such as morning routines and bedtime, waits could extend to one hour and forty minutes for assistance. Another described delays of 30 to 60 minutes for hoist transfers because staff were unavailable after lunch breaks.
The constant rotation of agency staff also affected care continuity, with one patient expressing that they did not always feel safe due to frequent changes in caregivers.
Management and Leadership Issues
At the time of inspection, the service operated without a CQC-registered manager, though the provider was actively recruiting for this position. The report stated that management arrangements failed to ensure consistent, high-quality support, and there was insufficient oversight to drive improvements and prevent avoidable harm.
Positive Aspects and Improvement Plans
Despite these criticisms, inspectors observed that most staff were kind and caring, and many patients expressed general satisfaction with their care. One resident described staff as "amazing," while families praised the team as approachable and like an extended family.
CHD Living has implemented several corrective measures, including:
- Introducing a new digital compliance platform
- Updating supervision and appraisal programmes
- Retraining staff in pressure area care, catheter management, and record-keeping
- Reviewing medication management systems to reduce error rates
- Launching a refreshed activities programme featuring therapy dog visits and sensory sessions
The provider has also appointed a new registered manager with extensive rehabilitation experience who is expected to join shortly. A CHD Living spokesperson stated: "We took the CQC's feedback extremely seriously and have taken clear steps to improve. We remain confident in the actions we're taking and look forward to demonstrating our progress."
Service Overview and Current Status
Kingston Rehabilitation Centre provides residential and outpatient care for up to 36 people, including those with complex neurological conditions. During the inspection, 28 individuals were receiving support. The CQC rated the service as "requires improvement" overall, with specific concerns regarding safety and leadership. The centre must now address the identified issues to meet regulatory standards.
