CQC report explained · a nursing home
What the CQC found at Kingfisher Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found infection control concerns, poor repair in some areas, inadequate domestic staffing and gaps in staff training. They also found that some risks and medicines were not assessed or recorded well enough.
- Effective?
- Good
- This question was not inspected in this visit. The report says ratings for questions not inspected were carried over from the last inspection.
- Caring?
- Good
- This question was not inspected in this visit. The report says ratings for questions not inspected were carried over from the last inspection.
- Responsive?
- Good
- People received personalised care and had communication plans. Activities were available, although inspectors did not see everyone taking part and some activities were not very meaningful.
- Well-led?
- Requires improvement
- Management checks had not found the problems identified by inspectors. Records did not always show that risks were reviewed or that care and mouth care had taken place.
What inspectors found, July 2023
Rated Requires Improvement; inspectors found kind, person-centred care but concerns about infection control, staff training, medicines and management oversight.
Inspectors visited the home without warning on 13, 15 and 19 June 2023. They spoke with people, staff, relatives and health professionals. They reviewed care records, medicines records, staff files and management records.
People generally felt safe and staff were described as caring. Care was personalised, activities were available and the home worked with health professionals. However, some areas were not clean or well maintained, domestic staffing was not enough, and staff training records had important gaps.
Inspectors also found that some risks and medicines were not assessed or recorded well enough. Audits and other management checks had not identified the problems. The home was rated Requires Improvement overall, with Safe and Well-led rated Requires Improvement and Responsive rated Good.
Personalised care
Inspectors found that care plans were individual and reflected people's needs, choices and preferences.
“People received individualised care which met their needs.” from the report
Kind staff
People, relatives and health professionals gave positive feedback about staff being caring, warm and supportive.
“People we spoke with were happy with the service and the staff.” from the report
Activities
The home offered activities on most days, including baking, arts and crafts, karaoke and exercise. People also went out for meals and trips.
“The service had an activity programme which covered most days with 1 or 2 activities a day.” from the report
Safeguarding knowledge
Staff knew how to recognise and report abuse. People told inspectors they felt safe.
“Staff had the knowledge and confidence to identify safeguarding concerns and act on them.” from the report
Working with health professionals
The home worked with local health services to support people's healthcare needs and placements.
“The service worked in partnership with the local doctor's surgeries and community health teams.” from the report
Cleaning and infection control
seriousInspectors found dirty areas, dust, food debris, damaged surfaces and empty hand gel dispensers. They were not assured that the home and its equipment were cleaned and maintained properly.
“We were not assured the provider had effective arrangements in place to ensure the home and its equipment was properly cleaned and maintained.” from the report
Staff training
seriousTraining records showed gaps in manual handling, first aid and specific physical intervention training. One person's risk plan required training that staff supporting them had not received.
“This meant staff were not trained to follow the risk management plan which could put people and staff at serious risk of harm.” from the report
Medicines and risk planning
needs fixingSome emergency medicines, allergies and medicines given when needed did not have enough risk assessment or clear instructions. Medicines were not always stored in line with guidance.
“Risk assessments were not always in place where needed.” from the report
Management checks and records
seriousAudits did not identify several problems found during the inspection. Records did not always show that risks had been reviewed or that care had taken place.
“Whilst some audits had been undertaken to monitor the quality and safety of the service, these had not been fully effective.” from the report
Meaningful activities
minorInspectors did not see everyone taking part in activities. Some staff felt more activities and more opportunities to go out were needed.
“During the inspection we did not see everyone engaged in activities and some activities were not very meaningful.” from the report
- 01What has been done to improve cleaning, deep cleaning and repairs, and how is this now checked?
- 02How many domestic staff are currently in place, and how will you prevent the home becoming dirty when there are staffing gaps?
- 03How do you check that every member of staff has completed the training required for each person's risk plan?
- 04How are emergency and PRN medicines, allergies and medicines given away from the home now assessed and recorded?
- 05What changes have been made to management audits and records since the CQC inspection?
This was an unannounced focused inspection that looked particularly at infection prevention and control under Safe; Safe, Responsive and Well-led were reported, while other question ratings were carried over from the last inspection. This explanation was written from the published report of 27 July 2023 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, December 2020
Inspected but not rated; inspectors found strong infection control arrangements at Kingfisher Court.
The inspection took place on 30 November 2020. It was an announced thematic review linked to the coronavirus pandemic. Inspectors looked at infection prevention and control in the home.
Inspectors were assured that the home was managing visitors, shielding, social distancing, admissions, personal protective equipment and testing safely. They were also assured about cleaning, infection outbreak procedures and the infection control policy.
The home had a detailed plan for keeping relatives informed during lockdown. Staff teams were kept separate, cleaning touch points took place every hour, and activities were adapted to support people's wellbeing.
This inspection was not given an overall rating. The safe question was also marked inspected but not rated, so the report does not provide ratings for the home's wider care.
Communication with relatives
The home had a clear plan for keeping relatives informed during lockdown and supported people to stay in touch in ways they preferred.
“Communication with relatives was open and transparent on the reasons for lockdown.” from the report
Frequent cleaning
Cleaning was shared across the staff rota, with touch points cleaned every hour.
“cleaning of touch points took place every hour.” from the report
Separate staff teams
Staff were divided between the two floors and did not mix. Inspectors said this supported continuity and stability.
“This has not only provided continuity of care for people but also provided stability and given staff confidence.” from the report
Person-centred activities
The home provided activities intended to support people's wellbeing and adapted them to individual preferences.
“The staff team have worked tirelessly to ensure activities were person centred and fun.” from the report
Inspectors raised no specific concerns in this report.
- 01How are the infection control arrangements described in the report being maintained now?
- 02How often are touch points cleaned, and who checks that this is done?
- 03How do you keep relatives informed and help residents communicate with the people they care about?
- 04Are staff still divided into separate teams, and what happens if someone needs to work across both floors?
- 05What ratings or inspection findings apply to Effective, Caring, Responsive and Well-led?
This was an announced thematic review of infection prevention and control during the coronavirus pandemic; the service was inspected but not rated and the other four questions were not assessed. This explanation was written from the published report of 17 December 2020 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
2 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- July 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2020Inspected but not ratedSafe: Inspected but not rated
- November 2018GoodSafe: GoodResponsive: OutstandingWell-led: Good
- November 2017
Registered with the Care Quality Commission on 6 November 2017.
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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