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Kingfisher Court Care Centre Requires improvement


Inspection carried out on 13 January 2021

During an inspection looking at part of the service

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 carried out on 4 September 2017

During a routine inspection

This inspection was carried out on 4 September 2017. The inspection visit was unannounced.

Kingfisher Court Care Centre is registered to provide accommodation and personal care for up to 40 older people and people with dementia and physical disabilities. On the day of our inspection there were 39 people using the service.

At the last Care Quality Commission (CQC) inspection on 26 February 2015, the service was rated Good in all domains.

At this inspection we found the service remained Good.

There were enough staff to meet people’s needs, however at times staff were rushed and their interactions with people were task focused.

People could be assured that they would receive their medicines as prescribed by their doctor. People’s health needs were met and where necessary they had access to health professionals.

Staff understood their responsibilities to keep people safe. Risks were assessed and measures put in place to prevent avoidable harm. Staff understood how to raise concerns about people’s safety if they needed to. The provider followed safe recruitment practices.

People were supported by staff who had received training and support to meet their needs. Staff felt supported and their competency in their role was checked.

Our observation of the lunch time service was that it was chaotic at times and that people sat for a long time in the dining room before their meal was served. Records did not reflect that drinks or snacks were served over a 24 hour period. Where people had dietary requirements, these were met and staff understood how to provide these.

People had consented to the care they received. The service supported people in line with the requirements of the Mental Capacity Act. People’s mental capacity to consent to their care had been assessed where there was a reasonable belief that they may not be able to make a specific decision.

Staff at all levels treated people with kindness and compassion. People were supported to maintain their independence. However at times people’s dignity was not protected.

The care needs of people had been assessed and were regularly reviewed to ensure they continued to be met. Staff had a clear understanding of their role and how to support people who used the service.

People had access to activities so that they could follow their interests and remain active if they wanted to.

The provider had sought feedback from people and their relatives and staff about the service. People and staff felt that the deputy manager was approachable and action would be taken to address any concerns they may have.

Systems were in place to monitor the quality of the service being provided and to drive improvement. These had not always been effective in identifying when records relating to people’s fluid intake had not been accurately maintained. Where systems had identified areas of concern, action had been taken to address these in a timely manner.

The provider was aware of their responsibility to report events that occurred within the service to CQC and external agencies. There was not a registered manager in post at the time of our inspection. It is a requirement of the provider’s registration that there is registered manager in post.

Inspection carried out on 26 February 2015

During a routine inspection

We carried out an unannounced inspection of the service on 26 February 2015. Kingfisher Court Care Centre provides accommodation for persons who require nursing or personal care for up to 40 people. On the day of our inspection 37 people were using the service.

We last inspected Kingfisher court Care Centre on 7 January 2014. At that time it was not meeting one of the essential standards. We asked the provider to take action to make improvements in the areas of meeting people’s care and welfare needs. We received an action plan dated 3 February 2014 in which the provider told us about the actions they would take to meet the relevant legal requirements. During this inspection we found that the provider was meeting these legal requirements.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were safe who used the service. Staff had received safeguarding training. Staff had a good understanding of safeguarding matters and the action they would take to report any concerns they found.

Risks were identified and assessed. Care had been planned for each individual to ensure the level of any risks were kept to a minimum.

Appropriate equipment was in place and each person had an emergency evacuation plan on their care file.

People and their relatives felt there was sufficient staff who were trained to support people and where relevant necessary procedures were followed to ensure safe care practices were always used.

People received their medicines safely and correctly. Systems were in place to ensure staff responsible for administering medicines did so without interruptions.

People were cared for and supported by knowledgeable staff. Staff assessed people’s needs to ensure they received effective care.

Staff received a robust induction, supervision, a yearly appraisal and attended relevant training courses to develop their skills and knowledge.

People gave their permission for care and treatment they received. The provider followed appropriate guidelines for the Mental Capacity Act (MCA) 2005and Deprivation of Liberty Safeguards (DoLS) which are a requirement of the MCA.

People received positive experiences at lunch time and were able to make their own choices. They received sufficient to eat and drink and where relevant food preferences were adhered to.

People were supported to maintain good health and had access to healthcare services to support their health needs.

People were cared for by caring staff who treated them with dignity and respect. Staff interacted well with people and they were encouraged to develop caring relationships with the people they cared for.

People’s choices and preferences were accommodated.

People were happy with the way the home was managed. They were confident to raise any concerns or complaints with the appropriate staff member. The culture of the service was open and transparent and people could share their views and experiences.

Inspection carried out on 7 January 2014

During a routine inspection

We spoke with five people about their experiences of living at Kingfisher Court. All of them told us they were very happy and settled and staff looked after them well. One person said, �I am happy here, it is marvellous. The staff help me when needed. I can make my own choices and decisions.� Another person said, �I am settled, my family can visit at any time. The staff are very good and always on hand if needed.�

We saw care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare. We found people were not always receiving appropriate support with maintaining their skin integrity.

We spoke with four people using the service about the cleanliness of the home. They all told us that they thought the home was clean and tidy. One person said, �It is very nice, staff clean my room and do my laundry.� Another person said, it�s a lovely environment, it�s kept clean and tidy.�

During our tour of the home we found it was clean and tidy and people�s rooms were personalised. We found the provider had taken steps to provide care in an environment that was suitably designed and adequately maintained.

We saw staff were being offered training and supervision to develop their knowledge and skills in relation to the job role they were to perform.

People using the service offered many positive comments about the care and support they received.

The complaints procedure outlined the steps that would be taken if someone raised an issue of concern to ensure this was dealt with to the person�s satisfaction.

Inspection carried out on 16 October 2012

During a routine inspection

People were supported in promoting their independence and community involvement. We saw there had been many parties held in the service such as an Olympics party and a harvest festival.

We saw there was an area called �Memory Lane� in the service which lent itself to providing a stimulating and orientating environment to older people. The corridor was set out in the theme of a street which had a sweet shop window displaying sweets from years gone by, a telephone box (which contained a telephone for people to use) and a bakery displaying a range of breads and cakes. There was also a �market stall� full of fresh fruit and we saw people helping themselves to the fruit to eat.

We spoke with four people using the service and they all told us they felt safe in the home. They all told us staff were always kind to them and they had not seen anything happen in the home which had caused them concern. One person said, �I feel very safe here� and another said, �I feel much safer here than I did at home.�

We observed positive interactions between staff and people using the service. There was a relaxed atmosphere and we saw that people using the service looked comfortable talking to staff.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

Reports under our old system of regulation (including those from before CQC was created)