Kexborough House Care Home

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. 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 the safe management of people’s medicines, care plans and environment.

This service scored 59 (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 had a proactive and positive culture of safety, based on openness and honesty. The service had effective systems in place to record accidents and incidents. Staff understood their responsibilities to raise concerns appropriately and had confidence action would be taken by the manager of the service.

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. We found evidence that the registered manager carried out some visits in people’s own homes prior to entering the service, to ease the transition and assess compatibility. The service had a positive relationship with the local GP, which ensured people received health care in a timely manner.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider did not always consider a person’s capacity under the Mental Capacity Act 2005 or their ability to consent to decisions. For one person whose finances were being managed informally at the service, memory concerns had been documented within their care plan, but guidance had not been sought from medical professionals about this person’s cognitive decline and ability to consent to the service supporting with financial matters. No specific mental capacity assessment was in place to determine this person’s ability to make financial decisions. The management team were responsive to the concerns raised and assured us appropriate action would be taken to ensure this person’s capacity and ability to consent was properly assessed. However, we positively found that safeguarding concerns were raised in a timely manner and investigations were conducted where necessary. Staff kept up to date with safeguarding training and could confidently explain how to keep people safe and free from harm. One person at the service told us, “I’ve been here a year, and I feel safe. It’s the staff that look after us that are really good. They [staff] are always there if I need them."

The provider did not always work well with people to understand and manage risks. Although we found no harm to people, we found that people’s risk assessments did not reflect some people’s needs, and certain risk assessments were not robust enough to guide staff to support people safely and consistently. For one person, who was on a modified diet and at risk of choking we found there was not a modified diet assessment within their care plan and no risks were documented in their choking risk assessment. The care plan had conflicting information about whether the person ate independently, or if they required assistance. We also asked the provider to explore any choking risks associated with people eating independently in bed. People’s pain and psychological risk assessments did not contain guidance for staff to follow when people’s maximum pain medication had been administered, and they experienced pain which had an adverse effect on their behaviour. People’s behaviour records were not always completed in full to ensure behaviour could be understood and managed more effectively in the future.

The provider did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care. During the inspection, we found 2 radiators without coverings. The coverings are a health and safety requirement to protect people in care homes from burns and scalds, particularly those with mobility issues or cognitive impairments who might unknowingly touch a hot radiator. We found some of the windows in the service were not safe or robust in preventing avoidable harm. Some windows did not have restrictors in place due to their age. They had to be propped open with objects to allow natural ventilation into people’s rooms. The banister height at the service was assessed and it measured below the minimum requirement for safety, which could allow people at the service to fall at height when mobilising on the stairs. However, the provider actioned this area of concern promptly. We found people’s room doors were propped open with small bins, which could compromise fire safety and put people at risk of trips and falls. One fire door at the service appeared weathered, which could impact on it opening and closing during an emergency. The provider was responsive in actioning the concerns we had raised to them and provided assurance about their plans to make the environment safer for people residing at the service.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met people’s individual needs. We observed good staffing levels and deployment at the service. There were robust and safe recruitment practices in place to make sure that all staff were suitably experienced, competent and able to carry out their role. People and relatives at the service told us they felt there were adequate numbers of staff to respond to people’s needs effectively.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. The environment was kept clean and hygienic and there was evidence of regular cleaning schedules in place at the service. There was sufficient Personal Protective Equipment (PPE) available for staff to use when providing personal care and support. The service was modernising the décor and facilities to support infection prevention and control. One relative told us, “The place could do with revamping, but it is clean, and they are well looked after."

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Although we found no harm to people, people’s medicines had not been managed effectively. A fridge used to store people’s medicines at the required temperature, was found unlocked and accessible in the communal dining room. This placed people at risk of ingesting or accessing these medications. Where people were prescribed ‘as and when needed’ (PRN) medicines, we found some protocols were not in place to ensure staff had detailed guidance specific to each person on how or when to administer these medicines. Some pain patches were not rotated as per clinical guidance and their application had not been documented appropriately. We found identification sheets in place for people, which included a photograph, to support staff to give the right medication to the right people. However, other important information such as allergies and a person’s date of birth were not included. Opening dates on some creams, sprays and eye-drops were not recorded and where MAR charts were hand-written, the written information was not always legible. However, the provider took immediate action following feedback from the inspection team.