12 April 2023
During an inspection looking at part of the service
Byron Lodge is a residential care home providing personal and nursing care for up to 61 people. At the time of our inspection there were 43 people living at the home. Some people using the service were living with dementia.
People’s experience of using this service and what we found
Systems in place to monitor the service were not always effective. Audits identified areas of some improvement but some issues were not actioned in a timely way. For example, the sluice bin had been identified for replacing on 6 March audit, but this was still not replaced when we carried out our inspection. This audit also identified that equipment should not be stored in bathrooms, but this was still evident on inspection and storerooms required attention, especially the decommissioned bathrooms.
People did not always receive person centred care. We observed the meal service on 2 units and found the meal time experience poor.
We found some concerns regarding medicine management. The provider could not always evidence people were given their medicines as prescribed. Following our inspection, the manager took appropriate actions to ensure systems improved.
We carried out a tour of the home with the manager and the home generally, was visibly clean, but deep cleaning was required to ensure equipment, furniture and storerooms were clean. Storerooms required organising and sorting out. The manager confirmed action had been taken following our inspection.
Risks in relation to people's care and support were in place. However, some people had lost weight and there were limited evidence to show how this was being addressed.
People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.
Staff were aware of what actions to take to safeguard people from the risk of abuse. The manager kept a record of safeguarding concerns and monitored the outcome.
Accidents and incidents were analysed but there was lack of evidence to show what actions had been taken to mitigate future risks. Following our inspection, the manager introduced a system to improve this analysis.
People, relatives, and staff spoke highly of the new manager and felt she was approachable and taking action to improve the service.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 25 December 2020).
Why we inspected
The inspection was prompted in part due to concerns received about medicines management, infection control, and leadership. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Byron Lodge on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to medicine management and governance and leadership.
Please see the action we have told the provider to take at the end of this report.
Follow up
We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.