13 June 2023
During an inspection looking at part of 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.