CQC report explained · a residential care home
What the CQC found at Kingfisher Court Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, safe recruitment, suitable risk assessments and safe medicines processes. Some covert medication decisions needed review, and some equipment needed cleaning or replacement, but the manager acted on these points.
- Effective?
- Good
- This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Caring?
- Good
- Staff knew people well and supported them patiently and respectfully. People were involved in decisions about their care and daily routines.
- Responsive?
- Good
- This question was not inspected during this visit. Its previous rating was used when calculating the overall rating.
- Well-led?
- Good
- Managers used audits and other checks to monitor care and safety. They shared learning with staff and involved people and relatives in developing the service.
What inspectors found, November 2022
Kingfisher Court Care Centre was rated Good after inspectors found improvements in safe, caring and well-led care.
This was an unannounced focused inspection on 12 October 2022. Inspectors checked Safe, Caring and Well-led. They spoke with people, relatives, staff and a visiting health professional. They also reviewed care records, medicines records, staff recruitment files, rotas and quality checks.
Inspectors found enough staff, safe recruitment, suitable medicines procedures and good infection control. People were treated with kindness and respect. Staff knew people well and supported their choices. Managers had improved checks and acted when they found problems.
The service had been rated Requires Improvement at the previous inspection in February 2021, when legal breaches were found. Inspectors found enough improvement and said the service was no longer in breach. The overall rating changed to Good, although Effective and Responsive were not checked during this visit.
Staffing and recruitment
Inspectors found that staffing was based on people's assessed needs and that staff were recruited safely. Staff training and competency checks were also in place.
“Staff were safely recruited. Safe recruitment processes were carried out for new staff members to ensure they were suitable to work at the service.” from the report
Safe medicines
People received medicines safely and at the right times. Records were up to date, and staff had regular training and competency checks.
“People received their medicines at the times they needed them and in a safe way.” from the report
Kind and respectful care
Staff knew people's routines and support needs. Inspectors saw patient, friendly and discreet care that respected people's privacy and choices.
“People were assisted by staff in a patient and friendly way.” from the report
Improved oversight
The management team used audits covering areas such as falls, weights, medicines and care plans. Inspectors found that action was taken when shortfalls were identified.
“The nominated individual and manager undertook a range of quality assurance audits to assess, monitor and review key areas of the service, and drive continual improvements.” from the report
Overdue dental appointments
minorSome people's dental appointments were overdue. The manager arranged for these to be booked during and after the inspection.
“some people required dental appointments to be arranged, as these were noted to be overdue.” from the report
Covert medicines
needs fixingSome decisions about giving medicines without the person's knowledge needed review with the relevant authority. The manager acted on this immediately.
“We identified that some covert medication decisions required review.” from the report
Manual handling equipment
needs fixingSome equipment needed replacement or deep cleaning. The manager responded during and after the inspection.
“We identified that some manual handling equipment needed replacement or deep cleaning.” from the report
Residents' meetings
minorResidents' meetings had been infrequent before the inspection. Future meetings were planned, and the new manager identified this as an area to improve.
“Although these had been infrequent prior to our inspection, we saw people and their relatives had been invited to attend, with future dates planned.” from the report
- 01What evidence can you provide that the improvements in staffing and risk management have been maintained since the inspection?
- 02Have all overdue dental appointments been arranged, and how are people's oral health needs monitored?
- 03Have the covert medication decisions been reviewed and authorised by the appropriate professional body?
- 04Which manual handling equipment was replaced or deep cleaned, and how is its condition checked now?
- 05How often are residents' and relatives' meetings held, and how are their views acted on?
This was a focused inspection of Safe, Caring and Well-led; Effective and Responsive were not inspected and their previous ratings were carried over when calculating the overall rating. This explanation was written from the published report of 11 November 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, February 2021
Kingfisher Court Care Centre rated Requires Improvement; inspectors found risks in staffing, medicines and care monitoring, although staff were kind and infection controls were assured.
This was an unannounced focused inspection on 13 January 2021. Three inspectors visited the home, spoke with staff and a healthcare professional, reviewed care, medicines and staffing records, observed care, and gathered telephone feedback from eight relatives.
Inspectors found that staffing levels were not always sufficient, particularly when staffing fell to four people. They also found gaps in weight monitoring, repositioning records and medicines management. The home's checks had not identified all these problems.
There were positive findings too. Staff were described as kind and knowledgeable. Relatives were generally positive about the care, and inspectors were assured about infection control. The overall rating changed from Good at the previous inspection to Requires Improvement. Safe and Well-led were both rated Requires Improvement, while the other key question ratings were carried over from the previous comprehensive inspection.
Kind and person-centred staff
Staff knew people well and were observed to be kind, caring and attentive. Relatives were also positive about the care and attention provided.
“Staff knew people well and were observed to be kind, caring and overall attentive towards people in their care.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infection, including PPE, testing, distancing and cleaning.
“We were assured that the provider was using PPE effectively and safely.” from the report
Safe recruitment
The home completed recruitment checks before staff started work.
“Safe recruitment processes were used to ensure only staff suitable for their role were employed at the service.” from the report
Staff support
Staff said they felt supported and valued, and received training and opportunities to discuss their work.
“Staff told us they felt well supported and valued.” from the report
Staffing levels
seriousStaff deployment was not consistently sufficient to meet people's needs safely. Inspectors saw a staff member leave people at risk of falls without arranging cover, and an inspector had to intervene.
“Staff deployment had not been consistently sufficient to keep people safe.” from the report
Medicines management
seriousRecords for creams and opened medicines were incomplete, patch instructions were not clear, some as-needed medicine guidance was not personalised, and a stock discrepancy could not be explained.
“Best practice guidance in the management of medicines had not been consistently followed.” from the report
Monitoring health risks
seriousWeight loss that should have led to healthcare referrals was not acted on promptly. Some repositioning records also showed gaps, increasing the risk of skin damage.
“We were not fully assured people were repositioned at the frequency required to reduce the risk of damage to their skin.” from the report
Governance checks
seriousThe home's monitoring systems and medicines audits had not identified all the problems found by inspectors. Some previously identified recording issues continued.
“The systems and processes that monitored quality and safety were not fully effective in protecting people from the potential risk of harm.” from the report
- 01What has changed to make sure staffing levels consistently meet people's needs, especially when staff numbers fall or there is an outbreak?
- 02How do you now check that medicines are recorded correctly, including creams, opened medicines, patches and as-needed pain relief?
- 03How do you identify weight loss and make sure referrals to a GP or dietician happen promptly?
- 04How do you check that people are repositioned as often as their care plans require?
- 05What evidence can you show that the three breaches identified in this report have been corrected?
This was a focused inspection of Safe and Well-led, with infection control included under Safe; the other ratings were carried over from the previous comprehensive inspection. This explanation was written from the published report of 5 February 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Kingfisher Court Care Centre
4 rated inspections over 7 years: the service has held its Good rating throughout.
- November 2022Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Kingfisher Court Care Centre →
- February 2021Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
Read what inspectors found at Kingfisher Court Care Centre →
- October 2017Goodstayed GoodSafe: GoodCaring: Requires improvementWell-led: Good
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- February 2014
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 24 January 2011.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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