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Archived: Kingfisher Court Requires improvement

The provider of this service changed - see new profile


Inspection carried out on 13 February 2020

During a routine inspection

About the service

Kingfisher Court is residential care home which provides accommodation for up to 66 people who require nursing or personal care. At the time of the inspection 38 people were living at the home.

People’s experience of using this service:

People were kept safe from harm. However, the records used to record how risks to people’s safety were monitored were not always fully completed. People were cared for by enough staff to keep them safe. People’s medicines were, overall, safely managed. The home was clean and tidy, and staff understood how to reduce the risk of the spread of infection. Processes were in place that ensured causes of accidents and incidents were investigated and measures put in place to reduce recurrence.

A new management team was in place and they had made efforts to improve the quality of the care people received. Whilst we saw some improvement since our last inspection, we were not yet assured that the quality assurance systems that were in place were fully effective. This meant we were not satisfied, at this moment, that the improvements were sustainable.

People, relatives and staff commented on the improved atmosphere at the home since the new management team was in place. They all found the new manager approachable and willing to listen to any concerns they had. The manager had a good understanding of the regulatory requirements of their role.

People’s needs were assessed to ensure their care was provided in a way that did not cause discrimination. Staff had completed training deemed mandatory by the provider, any gaps had been acted on and courses booked. People were supported to maintain a healthy and balanced diet. Where people received care from other agencies as well as this service, the two worked together to provide timely and consistent care. External healthcare professionals spoke positively about the care provided.

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

People received care from kind and caring staff. People liked the staff and felt able to make decisions about their care. People felt listened to and staff acted on their wishes. People received dignified and respectful care. People’s privacy was respected.

People’s personal choices and preferences were considered when care was provided. Care records provided guidance for staff to provide people with care in their preferred way. People were provided with opportunities to avoid social insolation by meeting others and to take part in activities. New staff had been recruited to further improve opportunities available to people. People felt able to make a complaint and were confident their complaint would be acted on. End of life care planning was in place.

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

Rating at last inspection and update

The last rating for this service was inadequate (published 9 September 2019). The service's rating has now changed to requires improvement

This service has been in Special Measures since 6 September 2019. During this inspection the provider demonstrated that some improvements had been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our reinspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 18 June 2019

During a routine inspection

About the service

Kingfisher Court is a care home, based in Sutton in Ashfield (Nottinghamshire). The service provides personal care for up to 66 people. There are three floors at the service. The ground floor is called ‘Acorn’, the middle floor is called ‘Birch’ and the top floor is called ‘Cedar’.

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

We observed that people received unsafe and neglectful care. There was no longer an open and transparent culture of reporting concerns and instilling change at the service.

There was a lack of guidance for staff to support people. Professional advice was not always recorded. Where guidance was provided, staff did not follow this which put people at high risk of harm. There was a culture of staff not updating records, having a poor handover of information and not reading records to understand people’s changing needs.

There were insufficient staffing levels at the service. This resulted in unsafe and undignified care – particularly at night. Staff and relatives had raised concerns about low staffing levels for six months, but change had not occurred.

The service was unclean. Despite our inspection findings, an NHS audit identified ongoing cleanliness concerns a month later. There has been a failure to ensure the service is clean and people are protected from ill health.

There has been a lack of learning from incidents occurring at the service. Actions have not been taken to prevent re-occurrence and concerns raised by staff, people and relatives have not been resolved.

People were not supported to consume adequate drinks. This put them at risk of dehydration. People’s specific textured diets were not documented or followed, this put people at risk of choking.

People were not always supported to have maximum choice and control of their lives. Staff did not always support them in the least restrictive way possible and in their best interests. The policies and systems in the service did not support effective practice.

Staff told us that they had an inadequate induction to the service. Records showed us that training was not always up to date to ensure staff were skilled. Staff lacked knowledge on people’s complex health conditions.

People’s experiences were no longer at the forefront of the service. Low staffing levels, and poor staff attitude resulted in people being left unclean and in an undignified state. The outstanding caring attitude was no longer present, and people were no longer treated with dignity and respect.

Complaints were not responded to effectively, to ensure that improvements were made. People, staff and relatives had already raised many of the concerns that we identified. However, action had not been taken to improve the service.

There was a lack of personalised care at the service. People’s preferences were not always recorded and people reported staff knowing them less well now. Staff advised that they try to follow people’s routines however the ethos of the service was changing to fit people’s routines in with general routines at the service rather than individual preferences.

People reported a lack of activities at the service since January. We observed minimal activities and stimulation on our visit. Efforts been made to recruit additional activities focused staff, the provider advised that care staff were expected to support activities where possible.

The service was no longer well led. There was a poor relationship reported between the staff and the registered manager. Staff had advised that they had reported concerns to the registered manager and provider, however felt a lack of action had been taken to improve the service. People told us and records showed us that the service was no longer working to its previously excellent standard. The provider had failed to recognise this and instil actions in a timely way. This left people at prolonged risk of harm and poor care.

Rating at last inspection:

The last rating for this service was Outstanding (Published 17 August 2018)

Why we inspected:

This inspection was brought forward due to concerns raised by staff, relatives and visiting professionals. Concerns included: unsafe staffing levels (particularly at night), people having unexplained bruises, a poor management culture, medicines concerns, dehydration, poor moving and handling of people, an unsafe analysis and response to incidents, cleanliness and not following infection control procedures, lack of activities, delays in care and people appearing unkempt. We received multiple concerns that the standards of care had reduced since our previous inspection. A decision was made for us to inspect and examine the risks.

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


We have found evidence that the provider needed to make improvements in all of our key questions. We identified eight breaches of Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These included regulations, 9, 11,12,13,14,16, 17 and 18. They had also failed to notify us of events occurring at the service. This allows us to monitor the safety of the service. This is a breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up:

After the inspection, we received an action plan from the service. This explained how they intend to make required improvements at the service. We have also met with the provider, to see how they are progressing with this action plan.

We will continue to monitor information we receive about the service, until we return as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Inspection carried out on 20 June 2018

During a routine inspection

The inspection took place on 20 June 2018 and was unannounced. Kingfisher Court is a care home that provides accommodation with personal care and is registered to accommodate 66 people. The service provides support to older people who may be living with dementia. The accommodation at Kingfisher Court is on three floors. Each floor has a large lounge and dining area and en suite bedrooms. The home had smaller lounges and family rooms, a café, library, hair salon and cinema. The home is in a residential part of Mansfield and the service has a vehicle and driver to support people on social activities and appointments.

Kingfisher Court is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of the inspection there were 44 people using the service. The service was registered in April 2017 and this is their first inspection, the service people received has been rated as Outstanding.

Staff were innovative and adapted social arrangements to meet people’s needs. There was an emphasis on supporting people to lead full and interesting lives. People were supported to have fun and enjoy a broad range of social activities and received care that reflected how they wanted this. The staff were motivated and committed to provide people with personalised experiences that exceeded their expectations. The registered manager encouraged staff to be imaginative in the way they provided care which recognised that people were at the heart of their service.

People participated in baking and cooking and were influential in designing the menus. People had a choice of meals and food and drinks were available at all times. Staff ensured people who were on specialist diets had their needs met. The service worked in partnership with health care professionals to meet people’s health care needs and this helped to ensure care was well organised when people moved between services.

People felt safe living at Kingfisher Court with the support of friendly, caring and approachable staff and management. The staff were passionate in their desire to enable people to experience excellent care and have new opportunities to enrich their lives. People’s care needs were identified and assessed and there were risk management plans in place to help keep them from harm and support their independence. People were not restricted due to perceived risk and supported to try new and different experiences.

People were involved in decisions about their safety and people were confident they were protected from unnecessary harm by staff who knew them well. The staff understood how to recognise signs of abuse and knew how to report their concerns. The registered manager reviewed incidents that occurred in the home and within other services, to determine if lessons could be learnt.

Positive and caring relationships had been developed between people and the staff. People felt that staff were compassionate and they had developed meaningful relationships with them. Relatives were informed of significant events and were able to trust the staff. People were treated with dignity and respect by staff who understood the importance of this and staff went the extra mile to ensure people lived their life independently and as fully as possible.

There was a culture within the organisation of striving for excellence and assisting people to reach their maximum potential. People benefitted from receiving a service from staff who were well trained. The registered manager’s commitment to the care of people living with dementia had extended to family and the local community. This had included training opportunities for people’s family members in how dementia affected people who used the service.

The provider forged and maintained strong links with organisations within the local community and worked collaboratively with other professionals. This enabled them to enhance the support, opportunities and experiences available to people living at the home to ensure people received care based on best practice. The care planning focused on people’s individual needs and preferences and people were central to deciding how care was planned. Care records were developed with people, individualised and easily accessible. These were reviewed when their needs changed to ensure it reflected their wishes.

Staff used their positive relationships and knowledge of people to ensure people’s care plans were followed. Staff recognised how information needed to be provided to ensure people’s understanding, including the use of information technology to help with communication. Staff valued people's differences and responded to each person's wishes. People’s diversity was fully recognised and promoted by the staff; people were supported to follow their religious beliefs and to maintain important family relationships.

The staffing was organised to ensure people had time to spend with staff, they were not rushed and could enjoy discussing their interests and spending meaningful time together. Care was responsive to people’s needs and available at all times throughout the home. Medicines were well managed, stored in line with national guidance and people received them at the time they expected. Working in partnership with pharmacy support, people’s medicines were reviewed to ensure they only had the medicines they needed. People lived in a homely, friendly and caring environment, which had been designed to support people living with dementia. Consideration had been given to how each area had been designed so people could safely walk in well lit rooms and corridors and have personal space to enjoy time alone.

People were supported to explore their care and support options and staff promoted their right to make their own decisions and respected the choices they made. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People and their relatives were encouraged to share their views to support the development of the service and share concerns. People knew how to raise complaints and these were investigated and managed in line with the provider’s complaints procedure. People and their relatives were kept fully informed during the complaint process and when shortfalls were identified actions were taken immediately.

Staff were proud of the service and felt well supported by the registered manager and the provider. The registered manager and provider promoted strong values and demonstrated their commitment to improving people’s lives by ensuring people received individual care which met their needs. People, relatives and staff felt the service was open and transparent.

There was a strong management team and people were included in developing the service and found the registered manager approachable. The registered manager and staff were committed to delivering a service that focused on providing a personalised service. The team worked collaboratively with people and their relatives to ensure the care provided met each person's needs. There were processes in place for people to express their views and opinions about the service provided. The registered manager worked with other professionals to continue to raise standards in the home and to drive improvement within the care environment.