Kingfishers Nursing Home in Bourne End has been rated ‘requires improvement’ by the Care Quality Commission (CQC), following its latest inspection.

The home provides nursing and personal care for older people with a range of physical and mental health needs, including dementia. It was inspected in November 2022. At this time, 32 people were using the service.

The CQC conducted a focused inspection of Kingfishers Nursing Home after receiving feedback from people who were concerned about safety. Questions were also raised about whether the service was being managed well. Therefore, these were the two areas inspectors looked at when they visited the home.


Inspectors found that environmental risks to people being cared for at Kingfishers Nursing Home were not fully managed. They also identified concerns about the management of medicines, safeguarding issues and accidents.

While inspectors were satisfied that immediate actions were taken when incidents occurred, they found that the service had failed to consider how they might connect to one another. Consequently, learning from such incidents was difficult.

While people using the service and their relatives provided positive feedback about its caring team, inspectors were also told that the service was sometimes short staffed. The service was working to address staffing problems by using regular agency workers, continuous recruitment and initiatives to keep existing team members.

Inspectors rated the service ‘requires improvement’ against the key question of whether it’s safe.


The CQC found that Kingfishers Nursing Home lacked effective oversight by the registered manager, who left during the inspection.

Inspectors found that some records were inaccessible or incomplete following the registered manager’s departure. Audits had not been completed consistently.

In addition, some incidents had not been reported to CQC in accordance with requirements. The service had also failed to provide an appropriate written response under their duty of candour for some incidents.

Inspectors rated the service ‘requires improvement’ against the key question of whether it is well-led.

Overall rating

For the key questions not considered at this inspection, Kingfishers Nursing Home was awarded the same ratings issued after its previous inspection. For effectiveness, responsiveness and caring, it was rated ‘good’.

However, the overall rating for Kingfishers Nursing Home has changed from ‘good’ to ‘requires improvement’ following this latest, focused inspection. The CQC has told the service that it needs to make improvements in the key areas of safety and leadership.

The CQC’s full report on Kingfishers Nursing Home is available on its website.

If you have experience of this care home, or any other health or social care service in Buckinghamshire, you can rate and review it right here on our website.

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Published on 16 Jan, 2023 (updated 19 Jan, 2023)

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