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Kingfisher Court Care Centre Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 5 February 2021

About the service

Kingfisher Court Care Centre is a residential care home providing accommodation and personal care for up to 40 people aged 65 and over, including people living with dementia in one adapted building. At the time of the inspection 25 were living at the service and one person was in hospital.

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

Staff deployment had not been consistent to ensure safe staffing levels were maintained. The provider took immediate action to address this.

Weight monitoring had not been fully effective. Repositioning charts showed some gaps in the expected frequency people required to be repositioned to maintain their skin integrity. Best practice guidance in the management of medicines was not consistently followed.

The provider’s internal governance, systems and processes had not fully identified the shortfalls in the expected care standards identified during this inspection.

Safe staff recruitment checks were completed before staff commenced their employment. Staff were knowledgeable about people’s individual needs. Relatives were complimentary about staff’s approach and considered them to be competent, experienced and skilled.

Staff had received safeguarding training and any concerns were reported and action taken to protect people from avoidable harm.

The prevention and control of infections were minimised due to infection control best practice being followed. Health and safety checks were completed regularly on the premises, environment and care equipment. Incidents were reviewed for themes and patterns and action was taken to reduce further risks.

Staff were positive about their role and shared the registered manager’s values in providing person centred, open and transparent care. Staff were clear about their role and responsibilities and received ongoing training and opportunities to discuss their work. Staff were positive and complimentary about the registered managers support and leadership style.

People, relatives and staff received opportunities to give feedback and this was used to develop the service. The provider and registered manager had met their registration regulatory requirements.

For more details, please see the full report which is on the CQC website at

Rating at last inspection

The last rating for this service was Good (published 12 October 2017).

Why we inspected

We received concerns in relation to the management of falls and how people were protected from avoidable harm. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

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 coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. 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.

The provider took action to mitigate the risks and staffing levels were reviewed to ensure staff deployment was consistent in meeting people’s individual needs and safety.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kingfisher Court Care Centre on our website at


We are mindful of the impact of the COVID-19 pandemic on our regul

Inspection areas


Requires improvement

Updated 5 February 2021

The service was not always safe.



Updated 5 February 2021


Requires improvement

Updated 5 February 2021



Updated 5 February 2021


Requires improvement

Updated 5 February 2021

The service was not always well-led.