During an assessment under our new approach
Date of Assessment: 25 September and 2 October 2025
Kingfisher Domiciliary Home Care Limited is a domiciliary care agency providing care to older people living in their own homes. At the time of our inspection, 4 people were receiving support with personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.
This inspection was to follow up on actions from the last inspection in November 2021. At that inspection the provider was in breach of a legal regulation relating to governance at the service. We had also made recommendations about COVID-19 testing, protocols for ‘as and when’ medicines, recruitment processes, the Mental Capacity Act principles and record keeping.
This inspection found 5 breaches of legal regulations relating to person-centred care, safeguarding, safe care, governance and staffing.
People were not placed at the centre of their care choices, and the service had not included them in any changes to their care plans. Care plans were not reviewed.
People were not supported to understand what being safe meant or how staff were able to support them from abuse. Staff had not received safeguarding training.
People were not informed about risks to their safety or involved in planning and mitigating for these risks. The provider did not ensure all risks to people had been identified and managed. Where risks had been assessed they were not reviewed or managed. Care plans lacked detail about what risks were present and how staff should mitigate against these.
People were not supported to receive medicines safely and as prescribed. Information about medicines was not recorded, or did not match, information in people’s care plans. The provider had not ensured staff were trained nor did they check staff competency to administer medicines.
The provider did not have a quality assurance and governance system in place.
The provider had not ensured staff were recruited safely or had ensured staff were appropriately trained. The provider’s recruitment system did not make appropriate checks to ensure staff were suitable to work with vulnerable people.
As part of our assessment methodology for services who may support people with a learning disability and autistic people, we assess if services are meeting the Right Support, Right Care, Right Culture (RSRCRC) statutory guidance. This includes: Right support: Model of care and setting maximises people's choice, control and independence. Right care: Care is person-centred and promotes people's dignity, privacy and human rights. Right culture: Ethos, values, attitudes and behaviours of leaders and care staff ensure people using services lead confident, inclusive and empowered lives. The service was not supporting anyone with a learning disability or an autistic person at the time of our inspection.
This service is being placed in special measures. The purpose of special measures is to ensure that services providing inadequate care make significant improvements. Special measures provide a framework within which we user our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/or appeals have been concluded.