We undertook an unannounced inspection on 5 June 2018. The last comprehensive inspection of the service took place in April 2017. We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance.

During this inspection we checked that the provider was meeting the legal requirements of the regulation they had previously breached. You can read the report from our last inspections, by selecting the 'All reports' link for, Kingfisher Lodge on our website at www.cqc.org.uk

Kingfisher Lodge 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 Lodge can provide care and support for up to 60 older people, some whom are living with dementia. At the time of our inspection there were 48 people living at the service.

The service provides accommodation in purpose built premises. The service is over two levels and has three areas Chaffinch, Lark and Robin. There are communal lounges and dining rooms. There was access on the ground floor to a large, secure, well-appointed garden area. This had shrubs and bright flowers, raised flower beds and ample seating. A balcony area was available on the first floor.

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.

Training had been reviewed and changed in regards to The Mental Capacity Act (2005). Competency assessments monitored knowledge gained from training. New documentation had been introduced in regards to consent to care and treatment. However, despite this revised training we found that consent to care had not always been completed in line with legislation and guidance.

Changes to the governance systems had made improvements. However, prompt progress had not always been taken to address shortfalls identified. The provider had not identified the mismanagement of some records and that people’s experience of staffing required further analysis.

Staff said they were well supported in their role through an induction, regular supervision and ongoing training. The service was bright, clean and well maintained. People had access to a safe and attractive garden. The environment was suitable for people living with dementia. People had space to move about safely and independently. There were private, communal and outdoor areas for people to spend their time in.

People were supported by staff who were kind and caring. People were treated with dignity and respect. Staff demonstrated passion and pride in the care and support they undertook. People had developed good relationships with staff and this enabled effective care strategies to be implemented. There was a constructive staff culture which had a positive impact on people’s well-being.

A varied programme of activities was available and people were involved in choosing future activities. There were systems in place to obtain feedback from people and relatives through meetings, reviews and surveys. Actions were taken to suggestions made.

The service had developed local community links by events and fundraising activities. Visitors were welcomed at the service and support was offered to relatives. Care plans were person centred. People received effective support with their health needs.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made a recommendation about advanced care plans. You can see what action we told the provider to take at the back of the full version of the report.

This inspection of Kingfisher Lodge was undertaken on 12 April 2017.

During August and September 2016, we received a significant number of concerns about staffing levels and care provision at Kingfisher Lodge. This information of concern was received from people’s relatives, staff and from healthcare professionals who had visited the service. As a result of that information, we undertook an unannounced inspection of Kingfisher Lodge on 19 September 2016. During the inspection in September 2016, we found five breaches of the Health and Social Care Act 2008.

Following that inspection in September 2016, and due to the level of concerns we had identified, we requested an urgent action plan from the provider to ensure that people living at Kingfisher Lodge were protected from being exposed to the continued risk of unsafe or inappropriate care and treatment. The provider engaged with us, and acknowledged the concerns we had identified within the service during the inspection. They sent us an action plan in October 2016 detailing how they intended to immediately safeguard people and achieve compliance with the regulations.

As a result of the inspection in September 2016, the service was rated as ‘Inadequate’ and the service was therefore placed in ‘Special measures’. Services in special measures are kept under review. During this comprehensive inspection in April 2017, we reviewed what improvements had been made at the service since they were placed into ‘Special measures’ following our inspection in September 2016.

Kingfisher Lodge provides accommodation for people who require nursing or personal care to a maximum of 60 people. At the time of our inspection, 34 people were living at the service. The service is split over two floors, ‘Chaffinch’ unit is on the lower floor with ‘Lark’ and a newly created unit named ‘Robin’ on the upper floor. Lark and Robin units primarily supported people living with dementia.

There was no registered manager in post during this inspection. 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 saw that the service had made improvements and this was reflected in the feedback we received from people, their relatives and staff. However, we found that consent to care and treatment was still not consistently sought in line with legislation and guidance. We have made a recommendation in relation to achieving compliance with the Mental Capacity Act 2005. In addition to this, although governance systems had improved we found they had not consistently identified the record keeping issues we identified during the inspection.

People spoke positively about feeling safe. We received mixed feedback in relation to staffing levels, however in general the feedback commented on how it had improved since the last inspection. In general, staff felt there were sufficient staff on duty to meet people’s needs. People’s medicines were managed safely, however we identified some recording omissions we identified to senior management. Infection control practice had improved and incidents and accidents were reviewed. People’s risks were assessed and recruitment was safe. Staff understood their responsibilities to safeguard people.

People said that care was effective, and we saw that staff received training, supervision and appraisal. Appraisal completion was currently poor but being addressed. New staff received an induction when they started employment. The service understood their responsibilities in regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to assess the requirement to lawfully deprive a person of their liberty when they lack the mental capacity to consent to treatment or

During August and September 2016, we received a significant number of concerns about staffing levels and care provision at Kingfisher Lodge. This information of concern was received from people’s relatives, staff and from healthcare professionals who had visited the service. As a result of this information, we undertook an unannounced inspection of Kingfisher Lodge on 19 September 2016.

When the service was last inspected in November 2014, we found the provider had failed to ensure there were adequate staffing levels to meet the needs of people at the service. The provider wrote to us in February 2015 and told us how they would achieve compliance with this regulation. During this inspection, we found the provider has not ensured staffing levels were adequate to meet the needs of the people at the service.

Kingfisher Lodge provides accommodation for people who require nursing or personal care to a maximum of 60 people. At the time of our inspection in September 2016, 47 people were living at the service. The service is split over two floors, with Chaffinch unit on the lower floor and Lark unit on the upper floor. Lark Unit primarily supports people living with a dementia type illness.

A registered manager was not in post at the time of inspection. 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. A general manager had assumed post in May 2016 and was currently undertaking the registration process with us to become the registered manager.

Following this inspection in September 2016, we wrote to the provider to outline the immediate concerns we identified and requested that an urgent action plan to address our concerns was produced. The provider responded to us within the requested timeframe. They acknowledged the seriousness of the concerns we had raised and the impact they were having on the quality of care provided to some people. We have since responded to the provider and requested they send reports to us at specified frequencies. These reports relate to the current staffing levels at the service in order to demonstrate to us that the service is able to meet people’s assessed needs.

The provider had not ensured there was enough staff on duty to consistently meet people’s needs. This placed people at the service at risk of not having their assessed needs met. Medicines were not always managed safely and medicine recording omissions made it unclear if people had received their medicines as prescribed. There were no effective systems in operation that ensured accidents and incidents were reviewed to reduce the risk of recurrence and risks to people. People were placed at risk through poor cross infection prevention practice.

There were insufficient systems to show that the service had met the Deprivation of Liberty Safeguard (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm. There was no evidence that the service understood the conditions attached to people’s DoLS or how they were being implemented. In addition to this, the provider was not consistently providing care in line with people’s consent and with mental capacity legislation.

Staff at the service were caring and people and their relatives spoke very highly about the caring nature of staff. We made positive observations of care provision, however we also received information from people and made observations of how staff were unable to be consistently caring through inadequate staffing numbers. People’s clinical needs were not consistently met in relation to pressure ulcers and diabetes care. In addition we found that where people required pressure r

The purpose of this inspection was to follow up one area of non-compliance from our previous inspection in July 2013. This was because the provider had failed to maintain effective records that related to people’s care and support.

The provider sent us an action plan that detailed how they would achieve compliance with this regulation. During this inspection the actions the provider told us they were planning to take, had been implemented within the service.

People we spoke with told us they were happy with the service they received. We spoke with three people who used the service and five members of staff during our inspection. One person that lived in the home told us “it’s lovely here the girls are so kind and they try very hard to please us”.

Staff we spoke with told us many improvements had been made and measures had been put in place to ensure all records were completed at each shift. Staff comments included; “things have improved greatly, we have structure to our day and residents are much happier". Another staff member told us, “we have received lots training around wound management and medication and have clear records that we complete every shift”.

At the time of our inspection there was no registered manager in place at Kingfisher Lodge.

Kingfisher Lodge is a care home which provides nursing and personal care for up to 60 people, some of whom have dementia. At the time of our inspection, 47 people were resident at Kingfisher Lodge, 20 people in the Lark unit [memory lane] and 27 people in the Chaffinch unit.

This inspection took place on 18 November 2014 and was unannounced. We returned on 19 November 2014 to complete the inspection.

There was a registered manager in post at the service. 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.

The service did not have adequate numbers of staff available at all times to meet people’s needs. This increased the risk of potential neglect due to the length of time people had to wait to receive care and support.

People and their families were positive about staff and the registered manager. People had developed caring relationships with staff and were treated with dignity and respect.

Staff worked closely with health and social care professionals for guidance and support around people’s care needs. The care records demonstrated that people’s care needs had been assessed and considered their emotional, health and social wellbeing. People’s care needs were regularly reviewed to ensure they received appropriate care, particularly if their care needs changed.

Training was available to ensure that staff had the necessary skills and knowledge to be able to support people appropriately and safely. There were systems in place to ensure that staff received support through supervision and an annual appraisal to review their on-going development.

There were clear values about the quality of service people should receive and how these should be delivered. The registered manager said “it’s about taking a holistic view of the person and their family, offering a consistent person centred service, which is effective and reflects the needs of the person”. Staff told us they valued the people they cared for and strived to provide a high quality of care. Relatives were confident that they could raise concerns or complaints and they would be listened to. Two thirds of staff thought the management team were approachable.

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