This unannounced inspection took place on 30 January 2018. At the last inspection on 23 and 24 January 2017 there were five breaches of regulations that we have followed up. Three breaches related directly to the care of people. These were that risks were not fully mitigated because of poor assessment, planning and evaluation of risks; records did not always provide an accurate, contemporaneous record and not everyone received the support or adequate monitoring of their dietary needs. We have seen improvements in many areas. This included the other two breaches relating to staffing and management systems known as governance.

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. Pla

The inspection took place over two days 23 and 24 January 2017. The inspection was unannounced but the provider was aware that we were coming back for day two. The last inspection to the service was on the 23 March 2016 and the service was rated as Requires Improvement overall. We identified two breaches which were: Regulation 14 HSCA Meeting nutritional and hydration needs and regulation 18: staffing. The provider sent us an action plan following the inspection telling us what they had done to make the required improvements. However at this inspection we still had significant concerns about staffing levels and felt they were not always appropriate to people’s needs or sufficient to provide timely, personalised care to people.

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 dec

This inspection took place on the 23 March 2016 and was un-announced.

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

We carried out an unannounced comprehensive ratings inspection of this service on the 5 August 2015 where we found this service was inadequate in a number of key areas including safe and effective. The overall rating for the service was inadequate. This means that the service has been placed into ‘Special measures’ by The Care Quality Commission (CQC).

The purpose of special measures is to: Ensure that providers found to be providing inadequate care significantly improve. Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made. Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration. Services placed in special measures will be inspected again within six months. If insufficient improvements have not been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the Provider’s registration.

In addition to placing the service in ‘special measure’ we also served a warning notice on Regulation 18 HSCA (RA) Regulations 2014 :Staffing which stated the service must have sufficient numbers of suitably qualified, competent, skilled and experienced staff. The warning notice was issued on the 18 September with a compliance date of 21 October 2015. We issued a warning notice because we had identified a breach of this regulation at the previous inspection which was carried out on two days the 21 and 29 October 2014. The service had made insufficient progress and the lack of suitably qualified staff in sufficient numbers in our view posed the most significant risk to people using the service.

During our unannounced inspection on the 5 November 2015 we carried out a responsive inspection to look at regulation 18. This report only covers our findings in relation to this regulation regarding staffing. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kingfisher House on our website at www.cqc.org.uk.

Kingfisher House is a service which can accommodate up to 91 people and can provide both residential, and, or nursing care. On the day of our inspection there were 72 people using the service. The regional manager told us the organisation had placed an embargo on new admissions. This had been in place and would remain so until they could satisfy themselves and the Local Authority that they were able to provide care safely. The service has specific units for people living with dementia.

There was 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 our inspection on the 5 November 2015 we noted some positive changes but noted there was still work to do. There were systems in place to monitor staffs performance and provide them with the training and support they needed for their job role.

People and staff reported that things were more stable regarding regular staffing and staffing levels were usually maintained at an adequate level. People received greater continuity of care and newly appointed staff were gradually replacing agency staff.

Job vacancies were off- set by reduction on the number of people using the service. A daily audit of people’s needs was used to calculate how many staff were actually needed to ensure people’s needs were met. Staffing rotas reflected usually adequate numbers of staff but there were times when the service did not have the number of staff it said they needed.

Staff vacancies were being managed by the manager through active recruitment processes that had been put into place and close monitoring of staff sickness and staff holidays which could have a negative impact on the business.

The manager was being supported by a regional manager who had been at the service for three weeks and was there every week day.

Expectations for staff had been made clear and the manager with support was monitoring poor staff practice through the performance management systems. The provider was also monitoring reasons for staff leaving in order to improve staff retention.

We felt the service had made sufficient progress in order to meet the requirements of regulation 18 .

The inspection was unannounced. We last inspected this service on the 21 and 29 October 2014. At this inspection we identified two areas which required improvement. We found there were not always enough staff to meet people’s needs in a timely way and made a compliance action. Whilst recognising that the service were trying to recruit new staff the impact of not having enough staff affected people’s experiences. We also identified concerns around how the service responded to people’s needs and how care records did not always help staff deliver effective care.

The service can accommodate up to 91 people and can provide both residential, and, or nursing care. It has specific units for people living with 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 this inspection we identified concerns with staffing levels and the use of temporary staff to deliver care which resulted in a higher level of dissatisfaction with the service and less cohesion amongst the staff team. We were given several examples of where staff did not adequately respond to people’s changing needs because they were not familiar with them. We also found care records were very complex which made it difficult to see at a glance what people’s main needs were. Staff who were most familiar with people’s needs reported that they were being asked to work in other areas of the home and some were leaving after many years of service.

We identified concerns around the safe administration of medicines. This was of a particular concern because we have identified concerns with medicines at previous inspections in 2014. In September 2014 we served a warning notice on medicines because the provider had not improved their practice from an earlier inspection in June 2015, when we had made a compliance action. When we inspected the service in October 2014 improvements in medicine practices had been made but unfortunately these had not been sustained.

Staff induction was good and most staff said they were supported for their job role but we identified gaps in staff knowledge which meant they were not always able to give care safely.

Staff were not knowledgeable about how to support people who lacked the capacity to make complex decisions about their health and welfare. There was poor understanding of advocacy and people were reliant on care staff.

There was poor monitoring of people’s weights to ensure they were adequately nourished and people reported unfavourably about the food.

Staff were not always responsive to changes in people’s health care and people’s needs were documented but records did not reflect people’s choices and preferences in care.

People social needs were not adequately met and some people were frustrated about the lack of opportunity to get out.

Staff were mostly caring but some people were anxious about the loss of regular staff and the continuity of care. They reported favourably about the care staff but had less confidence in agency staff.

People said they had opportunities to raise concerns and give feedback about the service they received but were not sure if their concerns were effectively addressed.

We had concerns about the management of the service due to what people were experiencing and the inconsistencies we identified around the home. Some people felt it was a good service whilst others were disengaged and largely unoccupied throughout the day. We have received a number of concerns about how people were supported in terms of their health and welfare. The home were proactive in addressing these concerns but were not identifying them for themselves which made us conclude that their quality assurance systems were not adequately robust and improvements were not sustained.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we have told the provider to take at the back of the full version of this report.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We conducted our inspection to assess if people’s medicines were being managed safely following shortfalls we identified during our visit in June 2014.

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 conducted our inspection to assess if people’s medicines were being managed safely. We found that records 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 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 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.

We inspected the service on the 01 July 2013 to follow up concerns identified at an earlier inspection on the 15 February 2013. In February we found the service was not meeting standards in relation to respecting and involving people that used services, consent to care, Care and welfare, meeting nutritional needs, assessing and monitoring the quality of the service and records.

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 on the 13 July 2012 and found the service was not meeting a number of essential standards. We identified improvements required in the care and welfare of people, nutrition, management of medicine, the safety and suitability of premises, staffing levels and supporting workers. We received an action plan stating how they were going to achieve compliance. We re-inspected the service on the 16 November 2012 and found improvements had been made in all of the previously identified outcomes. However we were still had concerns with people's care and welfare but considered the risk was reduced from a moderate to minor impact We identified non compliance with records and notifications-notice of changes. The service sent us a second action plan telling us what they would do to ensure compliance with the regulation.

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 spoke with ten people using the service and two relatives. We observed the care provided, including a short observation of lunch being served. People told us their needs were met and that staff were nice. One person said, “The staff are attentive and funny. They provide some activities here.” Another person told us that their needs were met. However they said, “I have complained about the food which is sometimes cold and served dry. I like gravy with my food. “A family member told us, “My relative has settled in well here and I feel the care provided to them is appropriate. I have no concerns at the moment.”

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.

We conducted this inspection to follow up on medicine management issues our pharmacist inspector identified during our inspection of 13 July 2012. During the inspection we saw that the service had made improvements to the way it manages medicines for people living there and we found that systems in place for monitoring were more effective in promptly identifying problems arising. However, staff told us that the review of corporate medicine management policies and procedures had still not been completed so we could not be assured that staff were managing people’s medicines to current corporate policy and procedures.

We spoke with ten people during our visit and observed the care practices, which included an observation of lunch time. The feedback received was mixed. Three people told us that they were waiting to go to bingo. They stated that they played draughts, quizzes and had regular entertainment provided. They said there were regular professional visitors to the home, including a hairdresser. They said staff were “Ok “and they had no concerns. They said their health and personal care needs were met.

We spoke with four relatives who did not raise any concerns. Two people told us they had found it necessary to complain but were satisfied with the way the service responded to it.

We observed lunch and where people required assistance with their meal by staff who did this is a respectful manner? . Seven people in one lounge were observed to be asleep until we interacted with them. One person told us there was nothing to do and they could not communicate with the other residents, some of whom had dementia or required nursing care. They said they would like to get outside. We did not observe anything for people to do. There were no magazines, books or board games.

The people living in Kingfisher House and their family members were very complimentary about this home and told us that they liked living there, the care staff showed them respect and worked hard to look after them. They also told us that they were comfortable in the home.

We carried out an unannounced inspection on the 21 October 2014.

Kingfisher House was last inspected 08 September 2014. This was a responsive inspection, by the pharmacy inspector. We issued a warning notice because medication was not being administered safely. The warning notice clearly specified what improvements we required the provider to make and the specific breaches. The warning notice was issued as a direct result of the provider’s failure to make the required improvements following a compliance action issued after the inspection in June 2014. Following the Warning Notice the provider took appropriate actions.

Kingfisher House provides accommodation for persons who require nursing or personal care for up to 91 people. On the day of our inspection there were 84 people using the service. The service provides accommodation according to need in four separate units. Each unit accommodates people with specific needs including those who require nursing care, residential care or dementia care.

There was 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 and associated regulations about how the service is run.

CQC is required by law to monitor the operation of the Mental Capacity Act, 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are in place to protect people where they do not have capacity to make decisions for themselves and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others.

Staffing levels were not adequate to meet people’s individual needs and we have Asked the provider to take action to address tis.

Improvements had been made in the way staff stored, administered and recorded people’s medicines which meant they received it safely. We were concerned how long it took to administer people’s medicines and were not confident people were getting their medicines at the prescribed time.

Staff had an adequate knowledge of how to keep people safe and individual risks to people’s safety wherever possible were reduced. Staff knew who to report concerns to if they had any concerns about a person’s care and welfare.

The service adequately supported its staff and had robust recruitment and induction processes for its new staff. All staff received sufficient training for their role and were appropriately supported.

People were supported to eat and drink enough for their needs, although some people were not happy with the quality of the food.

There were robust complaints procedures in place and people were consulted about their care and welfare. Where the service fell short of people’s expectations this was addressed.

There was a good programme of social activities which met people’s individual interests and hobbies. There was improved engagement with the community and family members were encouraged to join in with things provided at the home.

The service was responsive to people’s needs but we found differential levels of care provided on each floor which was indicative of insufficient staffing levels. Some care we judged to be more person centred than others.

The manager was making improvements in the service and was open and transparent. There were systems in place to judge the quality and effectiveness of the service to ensure it was continuously improved.

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