Kingfisher Court

Updated 27 July 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

Two inspectors carried out the inspection with the support of a specialist pharmacy inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Kingfisher Court is a ‘care home’. People in care homes receive accommodation nursing and personal care as a single package under one contractual agreement dependent on their registration with us. Kingfisher Court is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 4 people who used the service about their experience of the care provided. We spoke with 14 members of staff including the registered manager, deputy manager, registered nurses, chef, housekeeper and care staff. We also spoke with a visiting entertainer.

We reviewed a range of records. These included 7 people’s care records and multiple medication records. We looked at 4 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Following the onsite visits we continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We received feedback from 7 relatives, 1 friend and 2 health and social care professionals.

Updated 27 July 2023

About the service

Kingfisher Court is a residential care home which was providing personal and nursing care to 29 people at the time of the inspection. The service can support up to 39 people. The service is purpose built to provide specialist accommodation and rehabilitation facilities for those with acquired brain injury and associated neurological conditions.

People’s experience of using this service and what we found

People enjoyed living at the home and felt safe. However, improvements were required in some areas. We were not assured there was good infection prevention and control practice in the service, some areas would benefit from deep cleaning and other areas were in poor states of repair. Staffing levels for domestic staff were not sufficient. Gaps in training records put people and staff at risk of harm.

Relevant recruitment checks were conducted before staff started working at the service to make sure they were of good character and had the necessary skills. However, we did find that more robust procedures for checking full employment histories were required. We could not always be assured risks associated with people’s needs were always assessed appropriately or managed. More robust governance systems needed to be in place to monitor and improve the quality of the service provided. Records were not always in place to support actions taken.

Improvements were needed for medicines. This included risks not being appropriately assessed and not enough information to support people. We have made a recommendation about the management of some medicines.

Staff had received training in safeguarding adults and knew how to identify, prevent and report abuse. Staff worked collaboratively with health and social care professionals to support people with their healthcare needs. There was a system in place to allow people to express any concerns or complaints they may have.

Activities took place both inside the home and outside the home. Staff felt supported by management and enjoyed working at the service and felt staff morale was positive. Staff we spoke with were enthusiastic about their jobs and showed care and understanding for the people they supported.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support: People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. For example, people lived in an environment where we found infection control concerns and not enough staffing to support the cleaning of the home.

Right Care: Care is person-centred and promotes people’s dignity, privacy and human rights

Right Culture: The ethos, values, attitudes and behaviours of leaders and care staff ensure people using the service lead confident, inclusive and empowered lives.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was good (published 10 November 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kingfisher Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to regulation 12 safe care and treatment, regulation 18 staffing and regulation 17 good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.