A Kingston rehabilitation service where staff worked long shifts over many days has been told to improve.

The Care Quality Commission (CQC) found people had been put at risk of harm at Kingston Rehabilitation Centre, run by CHD Living, due to failings involving staffing, risk management and medicines.

The CQC found the provider was in breach of legal regulations for safe care and treatment, staffing and good governance. Inspectors visited the centre in September last year, after receiving safeguarding concerns about the service.

A CHD Living spokesperson said the centre's highest priority was the health and safety of those using it, while it was committed to providing safe and high-quality care. They said they took the CQC's feedback extremely seriously and had taken clear steps to improve.

In a report published this month, the watchdog said people were "continuously put at risk of harm" as the provider did not work well with people to understand and manage risks, while staff did not provide care that was safe, supportive and allowed them to do things that mattered to them.

The CQC's review of safeguarding investigations carried out by the home last year found some people had been put at risk of neglect by a lack of timely intervention, poor record keeping and inconsistent checks of catheters and pressure sores.

Poor skin integrity checks and a lack of timely intervention had possibly been the reason why one person had to undergo surgery.

While the provider had taken action to address these concerns, inspectors found gaps in records for turning and positioning people. They discovered daytime records had not been completed for two days for a person at high risk of pressure sores.

The CQC also found the provider did not always make sure medicines and treatments were safe and met people's needs.

Records last year showed medicine errors involving records, stock management and administration, with some incidents resulting in people not receiving their medicines safely and as prescribed.

Inspectors said the provider did not always manage or monitor people's safety, with measures taken to safeguard people not always being effective.

Healthcare professionals told inspectors people's conditions had not always been escalated, addressed and monitored appropriately.

One person said: "Staff make a genuine effort to understand and respond to individual care needs, but their effectiveness is sometimes limited by inexperience and a lack of structured support."

Inspectors found the provider did not always make sure it had enough qualified and experienced staff, or that they received proper support, supervision and training.

The number of agency staff used daily to cover shifts at the home also affected the quality of care, they said, with one person reporting they did not always feel safe because of the constant changes in staff.

One family member said: "Staffing levels are not enough at peak times, like getting up and going to bed. [My relative] asks to go to bed but it can be one hour 40 minutes' wait for staff to be available."

Another said: "Hoist can be a wait of 30, 40, 60 minutes due to shortage of staff, [my relative] is waiting to go back to bed as tired and they say that they are waiting for staff to come back from lunch."

Rotas showed some permanent staff were working 12-hour shifts on consecutive days, on one occasion for 10 days in a row.

The report said: "Management arrangements in place did not ensure good quality support consistently. At the time of this assessment the service did not have a CQC registered manager, but the provider was actively looking to recruit a manager with the experience and skills necessary for the home.

"There was continuous support provided for the home by the regional manager who knew the service and people well. However, areas for improvement identified during this assessment suggested there was a lack of management to oversee the quality of care being provided at the home and to drive improvement, making sure people were not at risk of avoidable harm."

However, inspectors praised most staff they observed for being kind and caring. Most people using the service expressed general satisfaction with their care, with one person describing staff as "amazing".

The centre provides residential and outpatient care for up to 36 people, including those with complex neurological conditions. At the time of the inspection, it was supporting 28 people.

The CQC rated the service "requires improvement" overall, and for being safe and well-led, which means it has to make changes to address concerns raised.

Actions already taken by the centre include introducing a new digital compliance platform, an updated supervision and appraisal programme and retraining in pressure area care, catheter care and record keeping.

It has also reviewed medication management systems, which has reduced error rates, and put in place a refreshed activities programme, including therapy dog visits, faith-based services and sensory sessions.

A CHD Living spokesperson said: "Ahead of the inspection, we had already recognised the need for leadership change and appointed a new, experienced registered manager.

They will be joining us shortly and bring with them a strong background in rehabilitation services, as well as proven leadership in clinical care. They will be working closely with our senior leadership team to drive improvements and provide greater oversight, accountability and consistency."

They added: "We were pleased that the CQC recognised several strengths in their report, including positive feedback from residents and families who described our team as 'approachable', 'amazing', and 'like an extended family'.

"They also noted the contribution of our in-house therapy team, and acknowledged progress in areas such as infection control, personalised care planning and collaborative risk reviews.

"We know there is more to do, and we are committed to making further improvements. These include finalising our care plan reviews in partnership with residents and their loved ones, strengthening senior team recruitment, and continuing to reduce agency use to support greater continuity of care.

"We remain confident in the steps we are taking and look forward to welcoming the CQC back in due course to demonstrate the progress we are making – and our continued commitment to delivering the safe, effective, and compassionate care every individual deserves."