Kingswood House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.



This is the first assessment for this service since the change of provider registered in September 2025. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.



The service was in breach of legal regulation in relation to safe care and treatment in relation to the ways people’s medicines were managed, infection control risks and premises and equipment

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff were not always alert to concerns about safety. Lessons were not always learnt to continually identify and embed good practice.



Leaders and staff were not always alert to risks and safety concerns, for example, no ‘Wet Floor' signage was placed outside the communal toilet after cleaning and mopping, leaving visitors and staff without any warning of the hazard. The registered manager acknowledged the error and took action, demonstrating a willingness to improve; however, oversight required further strengthening. Furthermore, the environmental risks we found had not been identified through the internal audits and oversight.



People and relatives were confident to raise concerns with the registered manager. One relative told us that when their family member had a fall, staff contacted them immediately to reassure them that the person was fine, had not been injured, and was being closely monitored. Records of incidents and accidents were being recorded appropriately.These were analysed to identify trends and shared learning.However, staff were not able to tell us about any recent learning from events or improvements made to promote people’s safety and wellbeing

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.



Peoples’ care plans included details of involvement and recommendations from external healthcare professionals such as any dietary requirements. Where individuals required support with routine health appointments for conditions such as diabetes, life-limiting illnesses, or general health screening, this was clearly documented and monitored to ensure care was delivered safely and responsively. One relative told us their family member attended regular outpatient appointments, and staff ensured transport was arranged in advance.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their rights, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately and worked collaboratively with the local safeguarding authority.



Most people felt safe with the staff and the care provided. Relatives told us they had no concerns about how staff protected their family member from the risk of abuse. A relative said, “[Person name] is safe here and staff cope well with them.”



The safeguarding policy provided clear guidance for staff to follow. This information was available in formats people could understand. Staff had completed relevant safeguarding training and felt confident to recognise, and report concerns both internally and to external agencies.



The registered manager and staff demonstrated a clear understanding of their responsibilities under the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Records showed that where people lacked capacity, relatives with the appropriate legal authority were involved in best interest decisions on their behalf. Where DoLS were in place, conditions were followed and met in line with legal requirements.

The provider did work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.



Risks to people’s physical health, care, and safety including managing health conditions were assessed, managed, and regularly reviewed. Care plans provided clear instructions to enable staff to support people safely and included equipment used in the delivery of care. Daily records and monitoring records were completed. Care plans and risk assessments were reviewed regularly and updated as people’s needs changed; however, the individuals and their relative’s contribution was not always clearly evidenced.



People and relatives were confident staff were trained for their role and to support people safely. We observed staff using equipment correctly and supporting a person to move safely from a wheelchair to an armchair. However, we also noted that one person was using a damaged pressure-relieving cushion despite there being no identified risk or instructions from a healthcare professional. Whilst there was no evidence of inappropriate care provided, this showed staff were not always monitoring whether support remained appropriate. This was raised with the registered manager and addressed promptly.



Staff were able to describe how people living with dementia expressed pain or discomfort and the best way to support them, consistent with their care plan. Assistive technology was used such as sensor equipment to alert staff when people at risk of falling were moving around.



Staff had been trained in fire safety. Individual personal emergency evacuation plans (PEEPs) were in place and accessible to staff via the digital care system on handheld devices, to support people safely in an emergency.

The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.



People and relatives comments about the environment were mixed. One person said, “It’s a nice place.” Relatives comments included, “New management made good noises and promises but nothing's changed from what I've seen so far” and “the place looks drab and could do with fresh paint.”



We identified environmental risks within the service. These included damaged walls and flooring, and unsafe communal and staff toilet facilities. Ground floor windows did not have restrictors fitted, presenting risks of falls from height and risk of unwanted intruders entering the care home. Some chairs in use were unstable and posed a risk of injury. One person was using a pressure cushion with a damaged outer cover, increasing the risk of injury and infection. Staff were unable to confirm how long these concerns had been present.



Equipment had been serviced as required. While bedrooms and communal areas appeared clean, cobwebs had not always been removed, indicating that cleaning was not consistently thorough. There was a courtyard available for people to use however, it lacked seating and access was restricted. Despite routine maintenance and audits, these issues indicated that environmental safety checks and measures to minimise risks required improvement. We raised these concerns with the provider and registered manager. Following the inspection, we were informed that window restrictors had been fitted. The provider must strengthen oversight and monitoring of environmental risks.



Personal emergency evacuation plans were accessible to staff for use in an emergency. Staff had received fire safety training, and regular fire alarm tests were completed. However, the emergency fire action plan had not been reviewed or updated since the provider was registered. This was raised with the provider and addressed promptly, with an updated plan shared with staff. Despite this, staff knowledge of fire procedures was inconsistent. For example, one staff member said they would evacuate all people at night and then inform the registered manager, which did not align with established guidance. This indicated weaknesses in the provider’s oversight of fire safety. The provider has been told to make improvements in this area.

The provider made sure there were enough staff deployed. Staff worked together to meet people’s day-to-day support needs. Staff were recruited safely. Some staff had not completed all the mandatory and refresher training that required updating. Staff received effective support, supervision and development.



Most people told us staff were available when needed. One person said, “Staff are responsive and there's always someone around.” Most relative told us there were enough staff, however, one relative told us their family member is not supported in good time to use the toilet, resulting in their family member being frustrated and loss of dignity.



The service was staffed with a consistent team of regular staff. The registered manager reviewed staffing rotas and adjusted them to maintain an appropriate skill mix on each shift. During the inspection, we observed staff remained in the dining area during breaks to ensure they could respond promptly to people’s needs. Feedback about staffing was mixed. While some staff felt there were sufficient staff on duty, others raised concerns about changes to the rota and how these impacted them.



Staff were recruited safely. Appropriate recruitment checks were completed including a Disclosure and Barring service (DBS) check before staff began working at the service, which helped ensure people were supported by staff who were suitable for their roles.



Staff received appropriate induction and most had completed the essential training for their role and to meet people’s specific needs in line with current standards. However, staff competence and practices were not always monitored, to ensure delivery of care was consistent with the training and best practice guidance. This was raised with the registered manager to address.



Staff received supervision and regular staff meeting were used to share information and keep up to date with changes in practice and policies.

The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. Although communal areas of the home were generally clean, some areas required further attention for example, cobwebs and dust remained.



The provider had not consistently ensured that people using the service and visitors were protected from the risk of infection. We identified several infection prevention and control concerns. These included stained, damaged and porous surfaces, areas of damp, and unsafe conditions in laundry and storage areas. Furniture in use, including a chair, posed cleaning risks, and equipment had been inappropriately stored in an unused shower cubicle. Personal items, including a hairbrush and a disposable razor, were left in a communal shower room, and staff were unsure who they belonged to. This was raised with the registered manager, and they discarded the razor immediately. However, this demonstrated the need for more effective infection control monitoring.



Staff had received training in infection prevention and control and were observed using personal protective equipment (PPE) such as gloves and aprons, appropriately. However, staff were not always alert to, or able to recognise potential risks of infection. For example, a person continued to use a damaged pressure-relieving cushion which could not be effectively cleaned.



Audit systems were not effective, as the concerns we identified during our visit had not been identified through internal checks, which demonstrated systems were not sufficiently robust or consistently followed to protect people from the risk of infection. The provider has been told to make improvements in this area.

The provider did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.



People received their medicines as prescribed. Relatives had no concerns about their family member’s medicines. One relative added, “[Person name] definitely gets their medicine on time and I think that's what's made the difference; it's peace of mind for us.”



We found that staff did not consistently manage and administer medicines safely or maintain accurate and reliable records. Prescribed eye drops and topical creams, which have a limited shelf life, were not always dated upon opening. This practice increased the risk of people receiving medicines that may have expired.



Some people were prescribed medicines on an ‘as required’ (PRN) basis with supporting protocols to guide staff when and how to administer them. However, staff did not consistently record the effectiveness of these medicines after administration. Additionally, records for people receiving their medicines in the form of transdermal patch applied directly onto the body were unreliable. There was no evidence of the previous patch being removed. This practice increased the risk to peoples’ health.



Medicines were stored safely, with appropriate arrangements in place for the management of controlled drugs and the disposal of medicines. The medicine fridge was located in the food storeroom and was not always locked, meaning its contents were accessible to staff not responsible for handling medicines. Medicines were administered by trained staff, but there was limited oversight to ensure staff practice was safe, consistent, and in line with best practice. These issues were raised with the registered manager and acknowledged action was needed.



We found no evidence that people had experienced harm however, these findings demonstrate people were placed at continued risk of harm by not managing medicines safely and oversight was not sufficiently robust. The provider has been told to make improvements in this area.