Kingswood House

This is the first inspection of the service since the change of provider who was registered on 2 September 2025.This assessment was prompted in part due to concerns raised around the quality of care people received, staffing and the management of the service. We identified 3 breaches of regulation relating to people receiving safe care and treatment and governance of the service.

We spoke with people who used the service and relatives, and staff including the registered manager, staff and the provider. We made observations using the Short Observational Framework for Inspection (SOFI) to help us understand the experience of people who could not talk with us. We looked at a range of records including people’s care records, staff records and management records including policies and procedures.

We identified concerns relating to medicine management, infection control and the environment. The environment was not adapted for people living with dementia to move around safely and appropriate signage. The environmental risks we identified were longstanding, indicating that leaders had not recognised or addressed them appropriately, placing people at risk of harm.

Governance and management systems were not always effective, lacked scrutiny and consistency. The provider did not have a service improvement plan to reflect feedback and issues they had identified, meaning opportunities to learn and improve the quality of the service were missed.

People’s needs and risks were assessed, managed and monitored. Care plans were reviewed regularly and provided sufficient guidance for staff to follow. However, individual’s and relatives’ contribution in reviews were not always evident. Staff did not consistently manage and administer medicines safely or maintain accurate and reliable records.

Systems were in place to ensure staff were recruited safely. Staff received training for their role; however, staff competency was not consistently checked to ensure their practice was safe. There were enough staff to support and meet people’s needs safely. We saw staff sought people’s consent before they were supported. They knew what abuse looked like and were confident to act upon safeguarding concern.

Staff knew people well and they sought advice from healthcare professionals when people health was of concern. Staff ensured people’s dietary needs were met and systems were in place to monitor their health and wellbeing. Some information was provided in large print; however, this was not always suitable for people living with dementia, who may benefit more from visual aids such as picture menus to support their choices. The registered manager assured us that action would be taken.

We have asked the provider for an action plan in response to some of the concerns identified at this assessment. In instances where CQC have decided to take civil or criminal enforcement action against a provider, we will publish this information on our website after any representations and/ or appeals have been concluded.