- Care home
Kingswood House
Assessment report published 3 December 2025
Contents
Ratings
Our view of the service
Date of assessment: 15 October to 23 October 2025. Kingswood House is a care home registered to provider personal care and nursing care. The service primarily supports autistic people or people with a learning disability. This was the first inspection of the service and the inspection completed was comprehensive. This means we looked at all the key questions of safe, effective, caring, responsive and well-led.
We carried out this inspection because the service was unrated. We have assessed the service against ‘Right support, right care, right culture’ guidance to make judgements about whether the provider guaranteed people with a learning disability and autistic people respect, equality, dignity, choices, independence and good access to local communities most people take for granted. We were not assured that the service was operating in line with the guidance due to concerns found during the inspection.
We found that the service did not learn from incidents and was not working to reduce restrictive practices for the people they supported. The service was not following its own policy in relation to learning from incidents. Although some work had started to improve this, this was not embedded and had not produced any positive results at the time of the inspection. Concerns raised by professionals had not been acted upon in a timely manner. The service was in organisational safeguarding with commissioning bodies. Some assessments were missing from people’s care plans and records were of poor quality and did not indicate plans in place were followed by staff. The service showed signs of disorganisation; people had health missed appointments and some relatives felt communication was poor.
The service had gone through instability in the management team and this had had a detrimental impact on the quality of care provided. There was a lack of oversight and supervision of staff, as a result staff had not been led by example or supported to work to the best of their abilities and in line with people’s agreed plans.
The provider was in breach of 3 legal regulations. These related to the safe care and treatment of people, safeguarding and good governance. We have issued 2 warning notices to the provider. In instances where CQC has begun a process of regulatory action, we may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward. This service has been rated inadequate and is being placed in special measures. The purpose of special measures is to ensure services providing inadequate care make significant improvements. Special measures provide a framework within which we use our enforcement powers in response to inadequate care and provide a timeframe within which providers must improve the quality of the care they provide.
People's experience of this service
People and relatives told us about their experiences of the service. Although some positive comments were expressed, the majority of feedback was negative. People expressed dissatisfaction with the care environment. People told us, “It’s like a hospital, the bed is like a prison mattress.” And, “I don’t like my room it’s not homely.” People had mixed feedback about staff approach. People told us, “I don’t like the staff, they don’t listen.” and, “Sometimes I like the staff.” and, “The staff are good.” Some people told us the care environment was noisy, and this upset them. A person told us staff made noise at night, and this interrupted their sleep. Not all people at the service were able to tell us verbally about their care experience. Records indicated people who were sensitive to loud noises had not been adequately protected from this and this had impacted on their wellbeing. The service operated models of working which did not appear to be in place for the benefit of individuals. The service had set mealtimes and menus. This limited people’s choice and did not promote their independence. Some people and relatives did not like the food, what choices were on the menu or the alternatives on offer. Relatives told us, “Our relative hardly gets the opportunity to produce their own meals, they like doing this but doesn’t get the right encouragement from staff.” and “The food is horrendous, there’s too many carbs, rice and jacket potatoes, things on the menu are not like what young people like to eat.” Most relatives expressed frustration at the ability of the service to respond to queries and requests. Relatives told us, “It took over a year to get the TVs working, the same with getting curtains in place, they just don’t do anything.” and, “They can’t get the basics right, we get told things are being done when they are not.”