- Care home
Kingswood House
We served Warning Notices on St Jude Care Homes Ltd on 20 May 2026 for failing to meet regulations related to premises and equipment, and good governance at Kingswood House.
Assessment report published 2 July 2026
Contents
Ratings
Our view of the service
Date of Assessment: 27 and 28 April 2026. Kingswood House is a residential care home providing support for up to 26 older people, including those living with dementia. At the time of this assessment, there were 16 people in residence.
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.
People's experience of this service
People and relatives said they felt safe and well cared for. They told us staff were around to help them whenever needed. One person told us they had a call bell, and staff came when they used the call bell. People were provided with equipment to promote their safety and independence.
People and relatives told us they had been involved in developing care plans; however, not all had seen them. Some confirmed they had taken part in care review meetings.
People received their medicines and saw the GP whenever they needed to.
People described the food as satisfactory overall, though some mentioned there was room for improvement. One person said, “Food is excellent” whilst another said, “Sometimes it’s good.”
People spoke positively about staff and described them as ‘kind’ and ‘caring’. We observed staff treated people with respect. However, there were instances where consent was not always sought; for example, staff placed aprons on people without engaging with them first.
People said staff respected their privacy and encouraged independence. People’s bedrooms were not always personalised and decorated to reflect their preference or interests. We also received mixed feedback from some people and relatives regarding the environment. One person said, “It’s a nice place.” Relatives felt the environment and décor could be better and described it as ‘drab and tired’ whilst another said, “Improvement in the garden would be nice; somewhere to sit and to look at flowers and birds.”
We observed people enjoying group activities in the lounge. One person told us they could only go outside if the door was open and staff were available. A relative told us “[Person name] enjoys the company of others, singers and spending time with staff talking, they love that.” However, people were unable to use the garden as there was no seating provided. One relative said, “Not very exciting outside; a little bit of colour would be nice.”
People and relatives knew who the registered manager was and felt confident to raise any concerns. Some relatives were aware of the new provider, having attended a meeting where information was shared about proposed changes and improvements. However, they reported that they had not yet seen any of these changes implemented.