During an assessment under our new approach
Date of Assessment 29 May 2025.
Kexborough House is a residential home, providing accommodation and personal care to older adults with a range of support needs, including those living with dementia. The home can accommodate up to 22 people. At the time of our assessment, 13 people were living at the service. We carried out a comprehensive assessment of the service covering all quality statements, in all key questions. At this assessment, we found areas of concern in relation to the management of medicines. Our findings showed that people were put at risk of harm because medicines on occasion, had not been managed safely. We also found some environmental concerns, such as radiators in communal areas without coverings and some windows on the top floors without restrictors and due to their age, were not robust. The banister height at the service was assessed and it measured below the minimum requirement for safety. However, the service actioned this risk immediately. People’s care plans detailed people’s preferences and staff knew people well. However, we found that some areas of record keeping required improvement in relation to risk assessments and behaviour monitoring. The provider, as a result was in breach of regulation 12, safe care and treatment. Additionally, we found that systems and processes were not robust in relation to medicines, care plans and environmental audits. This effected the services ability to correctly assess, monitor, and improve the quality and safety of care in which people received. The service was therefore, in also in breach of regulation 17, good governance. The provider was extremely responsive in actioning the concerns we had identified and as a result, evidenced to Inspectors their plans to ensure medications and the environment are safer for people residing at the service, including plans to strengthen their auditing systems. The service had a friendly atmosphere, and staff were observed to be caring and knew people’s needs well. People told us they felt safe and well-cared for at the service. There were enough staff, with the right skills and knowledge in place, to support people safely. The staff told us they enjoyed working at the service and that it fostered a positive work culture. One staff member told us, “Caring for the residents here is the best bit of my job. All the staff I work with are nice, we’re like one big family."