Kingfisher House Care Home

We found the following examples of good practice.

There was a system of regular COVID-19 testing for both people who used the service, staff, and visitors. All visitors, including professionals were subject to a range of screening procedures, including showing evidence of vaccination and a negative lateral flow test before entry into the service to protect people from the risk of acquiring infections.

There was a plentiful supply of personal protective equipment [PPE] for staff and any visitors to use. Hand sanitiser was readily available throughout the service. Staff had received updated training in infection control and in the use of PPE. Staff were observed wearing PPE.

Daily cleaning schedules were in place and all staff were involved in undertaking regular touch point cleaning.

At the time of this inspection the home was coming to the end of a COVID-19 outbreak. People

continued to receive prompt medical attention when they became unwell and relationships with health professionals remained positive.

Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve the service. We also met with the provider to confirm that all our key questions would improve to at least good.

Kingfisher House 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.

Kingfisher House site is purpose built and can accommodate up to 91 people in total. At the time of our visit there were 70 people living at the service. In Kingfisher House, downstairs is for people with personal care needs, commonly known as ‘residential care’ and upstairs is for people requiring nursing care. Next door and part of the registration is Spiller. This is purpose built accommodation for people living with dementia. Again this is split into two units with personal care downstairs and nursing care upstairs. There were 26 people in Spiller on the day of our visit and it can accommodate up to 29 people. Everyone can have access to outside space as there are gardens surrounding the accommodation.

The registered manager was present throughout the inspection visit. 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.

The registered manager was very responsive to feedback given and wanted to improve the service for people where ever they could. We received confirmation of actions taken following our inspection visit. These included the change from domestic showers to health care standard showers so that hot water could be continuously delivered at the correct temperature and not present a risk of scalding. The installation of the domestic showers had been commissioned by the provider and the usage had not been reviewed. This had placed people at potential risk. People had confidence in the management team and found the service to be well led. The management was approachable to people and staff spoke highly of them. There was a desire to drive improvement from monitoring service delivered and acting when matters needed addressing.

People at the service could expect a comfortable, clean and appropriate environment in which to live. People were very complimentary about the catering and food provided. People had access to appropriate healthcare to keep them well. There was a variety and range of activities for people to become involved with should they choose to do so. Relatives and friends could visit people whenever they desired. There were pleasant seating areas both inside and in the gardens.

People’s care records were well kept and the assessments and plans provided staff with clear information on how best to support people. Information about people’s history, likes and dislikes enabled staff to provide personalised care. Care plans had small details such as how people liked their tea served. Risk assessments were known by staff and followed to keep everyone safe. People were consulted and involved with their care. Plans were kept under regular review. Staff understood about choice and enabling people to make decisions for themselves where possible, but also how to support people where they lacked capacity.

Staff were well supported through provision of training to complete their roles effectively and given guidance, support and supervision with appraisals in place.

The service is registered to provide residential and, or nursing care. The service has four separate units and can accommodate up to 91 older people some who may have a diagnosis of dementia. At the time of our inspection there was one vacancy.

There is a registered manager in post. 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.

We noted since the last inspection there have been a number of visible improvements. The service was clean and welcoming. There was a lot of information around the service showing what was going on in terms of activities and changes which had been implemented as a result of feedback,

‘You said we did’ which showed the service listened and acted on feedback. In addition i-pads were placed around the service to enable people and visitors to give feedback which then went straight to the manager to access. The service published a newsletter and a team of activity staff provided different activities across seven days a week. There was evidence that a lot of staff training was taking place and staff practices were observed mostly as good.

However we identified a number of issues which were having an impact on the service delivery. The first was the staffing levels and whether these were actually appropriate to people’s needs. Staffing levels fluctuated and we saw even with the numbers of staff the service said they needed people did not always get the care they needed in a timely way. Care observed was largely functional around people’s needs but less so around the time people would like from staff. Some people were isolated and more vulnerable to declining health. For others who were able to socialise their lives were more enriched.

Risks to people’s safety were managed but this was not always clearly evidenced through the records because they were not accessed by staff delivering the care. Records were not always completed and updated contemporaneously or accurately reflecting changes in people’s needs.

Medicine practices were much improved and managed safely. Staff were familiar with people’s health care needs and took steps to prevent ill health or manage long term conditions. However records did not always show how this was done effectively.

Staff recruitment practices were adequate but could be improved upon.

Staff were supported through induction and training and were mostly familiar with people’s needs. However staff simply did not have the time to ensure everything was followed through correctly.

People were mostly supported to eat and drink in sufficient quantities for their needs and this was monitored. However the level of support people got varied and this was not always established depending on their needs but more in relation to the staffing allocation.

Staff had a good understanding of legislation relating to the Mental Capacity Act and Deprivation of liberties and its application. The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation.

People’s care plans were comprehensive but not accessed by staff who needed them to inform them of the care they should be providing. Records were not always updated as and when needed to reflect changes in people’s needs. Information was difficult to find which could result in people receiving the wrong care.

Social activities were provided across the service seven days a week but access to these were restricted either because the activities did not suit people’s personal preferences or because people would require support to join in and this was not always available. Some people were fully engaged with the service whilst others chose to be less so but there was limited evidence of how staff spent one to one time with people.

The service acted upon feedback to help improve the service it provided. There was an established complaints procedure which showed actions taken in response to people’s experiences.

The service was mostly caring and staff were highly regarded and considered kind and caring. However constraints around staffing levels impacted on people’s experiences and meant people’s independence and dignity was not always upheld.

The service involved and included people in the way the service was managed and care was delivered. There were many ways in which people could feed back their experiences but we found through our observations that care delivery was not always effective and many people would not be able to feed back their experiences due to their frailty or severe cognitive impairment.

The manager was working exceedingly hard to manage the service and support the staff. There were many audits in place to judge the quality and effectiveness of the care being provided. The manager was listening and responding to concerns but it was felt that due to the pressures of the job were not always available or did not always act on feedback.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in multiple regulations. You can see what action we told the provider to take at the back of the full version of this report.

We last inspected this service on 21 and 29 October 2014 and found it was not meeting some of the standards required and the location was rated as Requires Improvement overall. We carried out a further inspection on 5 August 2015. We rated the service overall as Inadequate as it had not made progress against the breaches identified at the last inspection and people were not a experiencing a good quality of care. The service was placed into special measures, which means the service was providing inadequate care and was given an initial six months but no longer than a year in which to improve. In addition to this we served a warning notice relating to the providers failure to comply with Regulation 18 HSCA (RA) Regulations 2014. Staffing. As we identified insufficient numbers of staff with the right skills, qualifications and experience to deliver effective care. The timescale to comply with the warning notice was 28 days. We re-inspected the service on the 5 November 2015 and only looked at one area of concern relating to the breach around staffing and whether people were receiving safe care. The service had made some improvement in this area and had partially met the requirements of the warning notice but it remained in special measures.

The service has four separate units and can accommodate up to 91 older people who require residential or nursing care and may have a diagnosis of dementia.

There is a registered manager in post. 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.

During the inspection in March 2016 we found the service was slowly improving. We found that a high staff turnover in recent months had destabilised the service and impacted on the ability to make the improvements required at a faster pace. The manager was not able to manage the service effectively as there was no support from either a clinical lead or deputy manager although we were advised during the inspection that one of these posts had been recruited too. There were also a number of nursing vacancies across the service. We observed that people experienced differential levels of care across the various units.

Care staff vacancies had been reduced to a minimum and there had been a dramatic decline in the use of agency staff which meant people felt that the continuity of care had improved. Staffing rotas and dependency tools to determine how many staffing hours were required to meet people’s needs would suggest staffing levels were adequate but people’s experiences and our observation identified this was not always the case. People’s care was compromised at times due to ineffective deployment of staff.

People felt safe and risks to people’s health and safety were well documented and steps were being taken to reduce risks to people. However staffing levels could potentially impact on people’s safety particularly in relation to staff’s response to call bells.

Staff understood their responsibilities to monitor people’s health and safety and to reduce risk and report any concerns they might have about people’s safety. Some staff felt the manager was not always approachable which could act as a barrier for them raising concerns.

There were safe systems in relation to medication practices and we were confident that people were receiving their medicines as and when they needed them by staff who were sufficiently competent and trained to administer medication.

The service was clean and organised and systems were in place to audit the cleanliness of the service.

Staff received support and training to enable them to perform their role. The induction process was robust. Training received by staff was good and induction covered how to meet people’s personal care needs. People raised concerns in relation to the language skills of some of the staff which made communication difficult. Staff were being supported to develop enhanced skills and receive training around people’s individual needs.

There were processes in place to support people with their hydration and ensure the risks from unplanned weight loss were effectively managed. However the dining experience for some people was poor as people did not receive adequate support around their individual needs and some people reported poor quality and choice of food. In advance of the inspection we had received a number of concerns about people becoming dehydrated, we found on the day that the service had improved how they manage people’s food and fluid intake.

People’s health care needs were clearly documented and showed us how staff were meeting people’s needs. However concerns were expressed by relatives and people using the service about some staff not being familiar with people’s needs which increased the risks of people not getting their needs adequately met.

Staff had a good understanding of legislation relating to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberties Safeguards (DoLS). The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation.

Overwhelmingly people were complimentary about the care and support they received from staff and staff expressed frustration at not being able to spend more time with people. The service worked inclusively with family members, visitors and other health care professionals. They also engaged with volunteers to help ensure people’s emotional and spiritual needs were met.

Staff tried to deliver care according to people’s assessed needs and wishes but this was sometimes compromised due to staffing levels. However care observed was compassionate and delivered in a calm, engaging way. They was a great deal of laughter from people and staff at the service and people appreciated being supported by cheerful staff.

People were involved and consulted about their care but it was recognised that some people found it hard to engage in care planning and it was not always clear how their views were taken into account.

There was an established complaints procedure which was understood by people and there was evidence that complaints/ comments were acted upon in a timely way to improve the service.

The service tried to meet people’s individual needs and provided lots of different activities. However some people were not engaged throughout the day and there did not appear to be sufficient opportunities for everyone to have activities that were appropriate to their needs.

Care plans were mostly up to date and showed people’s needs once assessed were regularly updated to ensure the plan of care remained relevant to their needs.

The service was well managed but we identified gaps in service provision due to vacancies and change in staffing and not having an effective management team in place.

Communication was improving and we found records reflected people’s needs with sufficient management oversight.

Audits were regularly completed to assess the quality and effectiveness of the care provided but we felt these need to be strengthened to ensure everyone experienced a good standard of care and pockets of good practice are the norm across the whole service.

We found breaches of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

During this inspection, we found that records overall assured us medicines were being given to people as intended by prescribers. However, at the time of our inspection we noted several medicines that had not recently been administered because there had been delays in obtaining them. We noted some good information available about people’s medicines but also a lack of written guidance about some medicines prescribed for administration at the discretion of members of care staff.

We noted that care staff authorised to handle and administer people’s medicines had received recent training and had been assessed as competent to undertake medicine-related tasks.

We noted that not all care staff authorised to handle and administer people’s medicines had received recent training or had been assessed as competent to undertake medicine-related tasks.

We spoke with 15 people who used the service. We also spoke with three relatives, ten members of staff and observed the care being provided at different times of the day in each of the four areas in the service. We looked at four care plans and other care records. We looked at staff training and induction records, the homes annual quality audit and the dementia care audit. We looked at minutes of meetings, held with staff, people using the service and their relatives. We considered our inspection findings to answer questions we always ask; is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

There were sufficient staff on duty to meet people's need and we saw that people were regularly monitored for their own safety. The call bell system was within people's reach and we found staff responded quickly. Where people had been assessed as unable to use the call bell, records showed us that staff carried out frequent visual checks to ensure people's safety.

Staff checked our identification and kept a record of all visitors entering the service which meant that people were kept safe. People were able to move freely about but there were systems in place to prevent unauthorised access.

We saw that staff received annual updated training in protecting people from abuse and had access to policies and procedures so that they knew what actions they should take to keep people safe. The manager had taken appropriate action in response to events affecting the well-being and, or safety of people using the service and had responded appropriately to complaints and concerns.

People were given the care they required and we saw people receiving their medication safely, with efforts to reduce the amount of medication required for people living with dementia.

The environment was well maintained and there were sufficient staff employed for the purpose of maintaining and cleaning the service over seven days a week. Routine audits were completed to check that the building was safe and regular checks were completed on fire safety equipment and equipment used in the service such as hoists, and wheelchairs/ to make sure they were safe to use.

Is the service effective?

We observed the care provided and saw positive interaction between staff and people using the service. People were enjoying social activities provided and socialising with others. People's independence was encouraged and we saw them being offered appropriate choices, although we observed some poor interactions over lunch time which did not promote people's dignity because staff were rushed.

People's care was planned in a way which intended their safety and well-being. People's needs were assessed and evaluated regularly to ensure the care being provided was effective. Where risks had been identified steps had been taken to ensure the risk was controlled.

Is the service caring?

We saw some very good staff interactions and we saw displays of warmth and affection between staff and residents. Staff were tactile and knew people well which enabled them to respond to their needs appropriately. During the day we saw staff responding appropriately and quickly to people and saw some good team work between the staff.

We saw that the staff regularly engaged with relatives and tried to involve, include and keep them up to date with any changes to their family member's needs which meant the service considered the needs of the person being cared for and their extended family.

One person told us 'This is a wonderful place, staff are polite and nothing is too much trouble.' Another said, 'I like it here, they have looked after me since I have had problems with my legs, there is a good standard of care.'

Is the service responsive?

We saw that at busy times of the day, systems were not in place to ensure people's needs were met in a timely manner. Although there were enough staff the organisation of work was not effective or responsive to people's needs.

We saw a range of things for people to do during the day to keep them engaged and active. Activities were provided to meet the needs of individuals and there was good engagement with the local community and community groups. The service helped people stay connected with their past and kept life stories for each person to help staff know each person they supported a little better so they could respond to their individual needs.

We spoke with people who told us their health care needs were met and they received the services they needed, like chiropody, physiotherapy, and a choice of GP surgeries. We saw from people's daily records that changes to people's health needs were quickly identified and actions taken to prevent the persons health declining.

The manager was proactive in dealing with concerns and complaints and met with family members to try and resolve concerns. Equally staff told us that the manager acted quickly on behalf of their concerns and was driving up quality. An example given was the use of agency staff to boost staff numbers and an increase in activities for people who used the service.

Is the service well led?

We found that the new manager had begun to drive up improvement and standards within the service. They had established good links with the community, family members and other stakeholders. Changes to the services had been introduced gradually and only after speaking with staff and observing the care being provided. One example given was looking at the skills mix, recruiting more nurses and staggering staff breaks so there was always enough staff for the needs of people using the service.

We inspected this service because we had received a number of concerns about the service. The service has not had stable management over the last year and was without a permanent manager in place during this inspection. For this reason we wanted to see how the service was managing the quality of people's care and welfare.

During this inspection we looked at how the service was meeting people's needs. We case tracked four people; spoke with eight people who use the service and a number of relatives and health care professionals. We observed activities and support being provided and assessed the systems in place to monitor and evaluate the level of care being provided to people. Care plans were comprehensive and kept under review but we noted some gaps in record keeping so we could not always see that people's needs were being met in line with their plan of care.

The service was finding it difficult to recruit trained nurses to lead each shift. The management of the service was compromised because the manager was only covering and not permanently employed. They were only at the service two days a week and told us they had only been to the service six times since their employment. In their absence the head nurse was covering the service but was given little time to complete management tasks and was mostly directly delivering care. They told us they were only supernumerary about one day a week. We noted that there were systems in place to assess and measure the quality of care being provided including daily walk around to ensure care was being delivered effectively. However a number of audits were overdue and had not been completed since the last manager was in post. This meant we could not be assured of the quality of the service being provided.

During the inspection on the 01 July 2013 we found that improvements had been made. People were involved and consulted about their care and offered appropriate choices. People's care was planned and clearly documented and any changes in people's need were identified through regular reviews. Care records showed what actions staff had taken to ensure people's needs were met. Social activities were provided to meet people's social needs but this remained limited in its scope because of the number of people using the service and the time allocated for activities. We observed some good staff interactions in the unit for people living with dementia but in the other units we did not see people engaging in tasks around the home or being socially occupied when planned activities were not taking place.

Staffing levels were adequate although one floor was a staff member short because of staff sickness which meant staff were rushing around to ensure they met everyone's needs. Additional staff were available at lunch time to ensure people received appropriate support with their meals.

The service was clean with no unpleasant odours. We did not identify any hazards to people's safety.

One relative told us, 'The home has a good reputation, my relative is well cared for and I feel that staff love and care for them.' Another relative said 'I come in daily and am always made welcome, I see the same staff and I feel my relative is well looked after and safe.' Another relative was consulted and supported by staff with regards to the care of their relative. Staff reported that there were many visitors to the home and they often participated in care giving which meant they were encouraged to remain involved and consulted about care given to their family member.

We inspected the service again on the 15 February 2013 to check what improvements had been made. We observed the care, looked at records, spoke with seven people and observed care being provided for people who were not able to tell us about their experiences. We spoke with staff. We found the service was meeting people's identified health care needs but were not providing opportunities to promote people's autonomy, independence and community involvement. We also identified concerns about how people's dietary needs were met.

We found that systems in place to assess and monitor the quality of the services it provided were ineffective.

We identified improvements which had been made to the service since the last inspection on 13 July 2012, when we identified non compliance.

Care plans had improved and were more person-centred. However we identified gaps in care provision and gaps in record keeping.

We spoke with six staff and observed the care they were providing. Staffing levels had improved since the last inspection and we found no evidence of insufficient staffing.