Archived: Kingfishers Nursing Home

Updated 12 January 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by 1 Inspector, 1 Medicines Inspector and 2 Experts by Experience who provided telephone support to gather feedback from relatives. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Kingfishers Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Kingfishers Nursing Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post, however the registered manager left the service on the first day of our inspection, and was therefore not involved in the inspection process.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and Healthwatch, and reviewed information publicly available on the Healthwatch website. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

During the inspection we spoke with 10 people using the service. We also spoke with 23 relatives and 22 members of staff including 6 health care assistants, 1 senior healthcare assistant, 1 laundry assistant, 1 chef, 2 nurses, 2 care home advanced practitioners, 2 agency care workers, 2 housekeepers, the head housekeeper, the management consultant, the interim support manager, operations manager and nominated individual. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We also received email feedback from 3 additional members of staff.

We observed infection control and medicines practices, reviewed the environment and looked at 11 people's care records on the electronic care plan system, either in full or in part. We looked at 3 staff recruitment and supervision files. We also examined a variety of other records including 9 medicine administration records, accident and incident records, audits, staff rotas and cleaning schedules.

After the inspection

We continued to review records shared electronically and continued to seek clarification from the provider to validate evidence found

Updated 12 January 2023

About the service

Kingfishers Nursing Home is a care home providing personal and nursing care to older people with a range of physical and mental health needs, including support for people living with dementia. The service supports up to 35 people and at the time of our inspection 32 people were using the service. The care home operates from a large, detached house which has had a purpose-built extension added in the 2000s.

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

We found environmental risks to people using the service were not fully managed. We also identified concerns in relation to the safe management of medicines, and the management of safeguarding concerns and accidents and incidents. Whilst we were satisfied immediate actions were taken when incidents occurred, the service had failed to consistently analyse potential themes or trends to identify wider learning.

People told us they felt safe, and most relatives were satisfied their family members received safe care. A relative commented, “My view is that [family member] is quite safe…it is just the general atmosphere there and the interaction with staff that makes me feel that she is safe.”

Some people and relatives told us the service was sometimes short staffed. A relative commented, “I don't feel there are enough staff. The carers are absolutely brilliant. They are doing the care that they need to do to look after [person], but there is rarely any time for them to spend talking to her.” People and relatives also indicated the response time to call bells was variable, with a relative commenting, “Experience has shown that if the call bell is pressed, the response is not that quick.” We have made a recommendation in relation to staff deployment.

The service was working to mitigate the impact of staffing vacancies through use of regular agency staff, continuous recruitment and initiatives to maximise staff retention. Staff were safely recruited and a structured induction process was in place to equip staff with the skills required to provide safe care.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible, however the systems in the service were not operated effectively to support this practice.

People were supported by a service which lacked effective oversight by the registered manager. Some records were found to be not accessible or incomplete following the registered manager’s departure. Audits had been inconsistently completed. We found some incidents had not been reported to CQC in line with requirements, and the service had failed to provide an appropriate written response under their duty of candour for some incidents.

Some staff and relatives raised concerns regarding the responsiveness of the registered manager. Comments from relatives included, “I always thought [registered manager] was marvellous and listened, but he did not always carry through what he promised, such as emails that he said he would send but which never came” and “I thought [registered manager] was a very nice…man, but he did not communicate effectively with me. It appears to be well run, but I am not sure that tasks are delegated appropriately by management.”

The registered manager left the service on the first day of our inspection. The provider was committed to ensuring that, following the registered manager’s departure, any lessons learnt would be acted upon and that governance arrangements would be further improved. Prior to our inspection the provider had already provided additional support via an interim support manager and care consultant. Further investment was planned to improve governance, including a new call bell system.

Some systems were in place to gather feedback and a relatives meeting had been recently held. People and relatives told us there had been ongoing concerns regarding the quality of the food. The service had an action plan in place to address this area of concern. The provider had also taken steps to seek and respond to staff feedback. The service generally worked well with professionals and built links with the local community.

People, staff and visitors were protected from the risks of infection. The service presented as generally clean throughout. Staff received training in relation to infection control and wore appropriate personal protective equipment (PPE). Systems were in place to respond to outbreaks of infection, such as COVID-19. A relative commented, “Visiting is back to normal, but we have to wear PPE. I went in yesterday and I only had to wear a mask and have my temperature taken. We do have to wear all the PPE if there is an outbreak.”

People and relatives provided consistently positive feedback about the caring nature of staff. Comments from relatives included, “I would say that they are very caring and there are a couple in particular who are outstanding with their patience and kindness” and “They are amazing, are caring, patient, considerate and compassionate.”

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 4 July 2019).

Why we inspected

We received concerns in relation to safe care and the management of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kingfishers Nursing Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches at this inspection in relation to safe care and treatment, safeguarding people from harm, governance, consent, meeting the duty of candour and in informing the Commission of information they are required to.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.