Kexborough House Care Home

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. 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 good governance. Systems and processes were not robust in relation to medicines, care plans and environmental audits.

This service scored 61 (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 shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities. Leaders ensured there was a shared vision and strategy, and that staff understood and supported the vision, values and strategic goals and how their role helps in achieving them. Staff told us they were kept up to date about any changes made within the service and had opportunities to feedback on these developments or suggest improvements.

Not all leaders understood the context in which the provider delivered care, treatment and support. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. We found improvement was required around the auditing of people’s medicines and care plans. However, we did receive positive feedback from staff and relatives about leaders. One staff member told us, “Staff here are happy, we are shown we are valued and there’s an ‘open door policy’ with our manager, we can always speak to them and get support.” A relative told us, “The [manager] is very pleasant. They just muck in and is very hands on. Their door is always open, I just pop in. They take action and are always there if you need them, there is a lovely rapport."

The provider fostered a positive culture where people felt they could speak up and their voice would be heard. Staff understood their responsibility to raise concerns and were confident their voices would be heard as a result.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. The provider had policies in place regarding equality and diversity. There were fair recruitment processes in place which helped to protect the rights of staff under the Equality Act. Risk assessments and any reasonable adjustments were utilised, if required for staff.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Although systems and processes were in place to ensure oversight of the service, these were not robust in identifying or highlighting concerns. We found auditing systems required improvement for the management of people’s medicines, the service’s environment and assessing and recording risks within people’s care plans.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information with partners and collaborated for improvement. Professionals were positive about the service’s ability to work in partnership. A professional told us, “They discuss any concerns they have with us in a timely and responsive manner."

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. Quality assurance systems were not robust and the quality assurance systems in place required improvement to evidence continuous development within the service.