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Archived: Kingswood Home Inadequate

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating


Updated 8 April 2020

About the service

Kingswood Home is a residential care home providing personal care to 20 people at the time of the inspection. People had a range of health and support needs and included people living with dementia. The service can support up to 23 people.

People’s experience of using this service and what we found

People were not safe living at Kingswood Home. At the time of the inspection, a team of local authority social care professionals had been brought in to assess people’s care and support needs, with a view to moving them into other care homes. People were at risk of receiving unsafe care. Staff had not ensured people had sufficient to eat or drink and their needs were not effectively monitored. Staffing levels were unsafe and meant that people did not have the support or care at the time they needed it. People were not protected from the risk of neglect or abuse. One person who was at risk of choking was given the wrong texture of food which increased their risk of choking. Another person, who was at risk of skin breakdown, was not repositioned regularly according to monitoring records. Medicines were not always managed safely. Stocks of medicines did not tally with records to confirm that people received their medicines as prescribed. There was a strong smell of urine in some parts of the home indicating that cleanliness and hygiene standards were not maintained.

Staff had not completed all the training they needed to ensure people received appropriate care and support. Where training had been completed, staff demonstrated a lack of understanding in key areas, such as safeguarding and types of abuse. People were not always given the correct consistency of food, in line with their assessed risks. Some people presented as being very hungry or thirsty. Drinks were not freely available and people often had to wait for their drinks to be served at set times dictated by staff.

Because of the lack of staff available, people received a poor standard of care. They were not treated with dignity and respect. Care was not personalised to meet people’s needs. Care plans were detailed and provided information about people’s likes, dislikes and preferences, including their interests. However, there was a lack of activities to provide mental stimulation or to engage people.

The culture of the home was negative and staff were dissatisfied working there; some staff felt the registered manager did not listen to them and was not supportive. The registered manager demonstrated poor oversight and capability in their management of the home and of their legal responsibilities. A system of audits had been implemented but was not effective in identifying all the issues found at the inspection or by external professionals who had intervened at the service.

By the end of the third day of inspection, all service users had been moved from Kingswood Home to alternative care placements.

Due to the nature of this urgent responsive inspection and the enforcement action which proceeded it, we were not able to fully answer all of Key Lines of Enquiry (KLOEs) in this report. The report has, instead, focussed on the KLOEs of highest significance to people’s safety, care and welfare.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was Requires Improvement, (report published 24 April 2019).

At this inspection not enough improvement had been made and the overall rating has deteriorated to Inadequate.

Why we inspected

The inspection was prompted due to serious concerns received about people’s safety and poor quality of care people had received. In response to these concerns, CQC inspected Kingswood Home as a matter of urgency. Prior to the inspection, we were notified of an incident whereby a person using the service had died. Since the inspection, another person died in hospital. These incidents, as well

Inspection areas



Updated 8 April 2020

The service was not safe.

Details are in our safe findings below.



Updated 8 April 2020

The service was not effective.

Details are in our effective findings below.



Updated 8 April 2020

The service was not caring.

Details are in our caring findings below.


Requires improvement

Updated 8 April 2020

The service was not always responsive.

Details are in our responsive findings below.



Updated 8 April 2020

The service was not well-led.

Details are in our well-Led findings below.