Kingswood House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.



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 the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.



The service was in breach of legal regulation in relation to governance at the service

This service scored 50 (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 have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not consistently understand or respond to the challenges and needs of people and their communities. As a result, this vision was not reliably reflected in day-to-day practice at Kingswood House.



The culture within the service had been affected by the recent change in provider, resulting in some challenges and instability. The provider had not fully communicated their expectations or strategies to the staff team, and there was continued reliance on the previous provider’s policies. Despite these challenges, the registered manager provided a level of stability in the day-to-day running of the service. Staff reported that the registered manager was responsive and offered the support and reassurance they needed.



Feedback from people and their relatives about the new provider was mixed. While some relatives had attended meetings where proposed improvements were discussed, there was no evidence that these changes had been implemented.



Staff told us that recent changes and proposed new ways of working had affected their ability to perform their roles effectively. Provider oversight was not sufficiently effective; however, staff remained committed to delivering safe and high-quality care. This was evident despite the shortfalls identified, including the need for further improvements to internal monitoring systems.

The registered manager promoted an open and inclusive culture, provided leadership, and supported staff. However, the provider’s values and oversight were not sufficiently embedded, which had a negative impact on the safety and quality of the service.



Systems to monitor care delivery and support were in place, but they were not always effective or thorough enough to drive the required improvements. The registered manager acknowledged awareness of some of the issues identified during the inspection; however, there was no evidence that appropriate action had been taken to address them. The provider also acknowledged the oversight needed to improve to support effective leadership across all areas.



The registered manager was responsive in some instances when issues were raised, such as removing a damaged pressure cushion used by a person. However, they also confirmed that the person had not been prescribed pressure-relieving equipment, highlighting that day-to-day oversight was not consistently effective.



Despite these challenges, the registered manager demonstrated openness, honesty and accountability. They notified CQC about events which they are legally required to do so. Duty of candour was evident in response to incidents that included an apology when needed.



Staff had received training however, their practice was not consistently monitored, resulting in identified shortfalls and increased risks to people’s health and safety. Despite this staff described the registered manager as approachable and willing to listen to feedback.

The provider did not always ensure people felt they could speak up and that their voice would be heard.



Regular meetings provided staff, people using the service, and relatives with opportunities to share ideas, raise concerns, and discuss improvements. Many described an open and approachable culture, where they felt comfortable speaking to the registered manager without fear of unfair treatment. However, this confidence was not shared by all staff. Some reported they did not feel able to speak openly with the provider, expressing concerns that doing so could lead to negative repercussions. This was raised with the registered manager, who stated they had supported staff and provided reassurance.



Staff told us they felt able to raise issues openly with the registered manager, and a whistleblowing policy and procedure was in place to support them to do so. The registered manager actively encouraged the reporting of concerns and poor practice. For example, one staff member told us that when they raised concerns about poor practice, these were taken seriously and appropriate action was taken to prevent recurre

The provider did value diversity in their workforce. However, not all staff felt there was always effective inclusion, a fair culture and equity for people who worked for them. Some staff had flexible working patterns in place to support their caring responsibilities. However, some raised concerns about the impact of new rota arrangements on these responsibilities and on their protected characteristics. The registered manager told us they were working with the provider and staff to trial and review the new ways of working.



There were no formal reports of bullying or discriminative practices, however, some staff were hesitant to request leave at short notice, leading to negative consequences such as increased scrutiny or changes in working patterns. This affected staff morale, confidence, and openness within the workplace.



All staff completed equality and diversity training as part of their mandatory programme and understood the importance of treating colleagues, people, relatives and visitors with respect. Staff felt they were fairly treated by the registered manager.

The provider’s governance systems and processes were not fully effective in identifying shortfalls or driving improvement. A range of audits and monitoring tools in place were still not robust to provide clear oversight and ensure risks were acted upon.



Audits did not effectively identify key risks or provide accurate analysis to inform action. Internal audits and provider oversight were not sufficiently robust, as some areas were assessed as compliant despite the presence of ongoing issues. The environmental risks we identified were longstanding, indicating that leaders had not recognised or responded appropriately to these risks. Medication audits also failed to identify the issues found during this inspection.



Although the registered manager knew people well and spent significant time in the home, their oversight was not effective in ensuring safe practice. They completed daily walk-arounds to speak with people, and check staff practices and the premises. However, they did not always recognise risks which we identified. They also did not see opportunities to improve people’s experiences, such as making mealtimes more person-centred. They had not kept their knowledge up to date with best practice and did not effectively monitor record-keeping, particularly for ‘as required’ medicines and transdermal patches.



The registered manager had systems in place to review incidents and accidents and reported taking action to reduce recurrence. However, staff we spoke with were unable to describe any learning that had been shared with them. Oversight of staffing levels and training was maintained, but staff competency and day-to-day practice were not routinely assessed.



The registered manager told us they had raised areas for improvement with the provider and requested items such as new blinds and decoration, however, there was no evidence or documented record to support this. Residents’ and relatives meeting with the provider included suggestions and improvement, and assurance was given to have seating and better access to the garden. However, no action had been taken.



While the registered manager and provider understood their regulatory responsibilities, we were not assured that all risks to people’s health, wellbeing, and safety were fully recognised.



Provider scrutiny was limited, and there was insufficient assurance that audits were being completed effectively. Policies and procedures, including key emergency protocols, were not in place, and there was continued reliance on documents from the previous provider. Although the provider acknowledged that improvements were needed, no formal service improvement plan was in place outlining the actions and how these would be addressed. The provider has been told to make improvements in this area.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. Records showed people were referred promptly to GPs, district nurses, dietitians and other specialists when their needs changed. Staff told us communication with health professionals was positive and that joint visits or calls were used to coordinate people’s care.



We received positive feedback from a health care professional about the registered manager, staff and the care and support provided to people.



People were supported to maintain contact with their family. The registered manager told us they had established links with the local church and hoped to develop more opportunities for community involvement and external activities

The provider did not always promote continuous learning, innovation or improvement across the organisation. They did not consistently encourage creative ways of delivering equality of experience, outcomes or quality of life for people, and were not yet fully contributing to the wider development of safe and effective practice.



Leaders expressed a willingness to improve the quality of the service. However, there was limited evidence of action taken in response to identified concerns and issues, indicating that governance and monitoring processes required strengthening.



Systems for recording information were in place. However, we observed staff were not always alert to, or did not consistently recognise, where practice could be improved. This indicated a culture of acceptance and missed opportunities to deliver person-centred care enhancing people’s experiences. For example, at lunchtime, staff did not always set the table, which meant the mealtime experience was not consistently inviting or enjoyable.



The registered manager described lessons learned following an incident and the actions taken to provide reassurance to the person involved. Although staff were unable to clearly describe any learning that had been shared with them, we observed that staff responded appropriately to support a person and took steps to reduce the risk of them placing themselves on the floor.